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■^ 


THE 


CHIRURGICAL  WORKS 

OP 

PERCIVALL   POTT,  F.R.S. 

SURGEON  TO  ST.  BARTHOLOMEW'S  HOSPITAL. 
WITH  HIS  LAST  CORRECTIONS. 

TO    WHICH   ABE   ADDED, 

A  SHORT  ACCOUNT  OF  THE  LIFE  OF  THE  AUTHOR, 

A    METHOD    OP 

CURING  THE  HYDROCELE  BY  INJECTION, 

AND    OCCASIONAr, 

NOTES    AND    OBSERVATIONS. 


SIR   JAMES   EARLE,  F.  R.  S. 

SURGEON  EXTRAOHDINAHT  TO  THE  KING,  &C. 


A  certis  potius  et  exploratis  petendum  esse  preesidium;  id  est,  his  qua:  Experientia  in  ipsis 
curationibus  docuerit ;  sicur  in  eaeteris  omnibus  actibus :  nam  ne  agricoiam  quidem  aut  gubernd- 
torem  disputatione,  sed  usu  fieri.  A.  CORN.  CELSUS. 


FIRST  AMERICAN,  FROM  THE  LAST  LONDON  EDITION. 

IN   TWO    VOLUMES. 
VOL.   I. 

PHILADELPHIA: 

PUBLISHED    BY  JAMES    WEBSTER,  NO.  24,  SOUTH  EIGHTH  STREET. 

William  Brown,  Printer. 

■     '  1819. 


""""^^r^/^ 


4^/ 


/r/9 


CONTENTS  OF  VOL.  I. 


Page 

A  SHORT  Account  of  the  Life  of  the  Author         ....        -  i 
Observations  on  the  Nature  and  Consequences  of  those  Injuries  to 

which  the  Head  is  liable  from  External  Violence      -        -        -        -  29 

Wounds  of  the  Scalp 31 

Effects  of  Contusion  on  the  Dura  Mater,  and  Parts  within  the  Scull  44 

Contusion  with  Wound 63,  65,  76,  78,  83 

without  Wound         -        -        -        -        -        .      67,  70,  73,  74, 

Contusion  joined  with  Extravasation        ------  80 

Separation  or  Destruction  of  both  Tables  of  the  Scull  from  Contusion  85 

Fissures  and  Fractures  of  the  Cranium  without  Depression      -         -  94 

Simple  Fracture        .--.--.---  121 

Fractures  of  the  Cranium  with  Depression        ...        -        -  135 

Extravasation  and  Commotion          -.....-  148 

Observations  on  that  Disorder  of  the  Eye  commonly  called  Fistula 

Lachrymalis             -         ..-.-----  179 

General  Remarks  on  Fractures  and  Dislocations         .        -        -        .  217 

Compound  Fractures        -...-----  265 

Of  Dislocations  in  general         ....----  287 

A  Treatise  on  Ruptures      ---------  305 

Those  capable  of  easy  and  immediate  Reduction        -        -        -        -  323 

Those  that  are  found  irreducible,  but  not  in  a  State  of  Inflammation  327 

Those  which  are  reducible,  but  attended  with  Pain  and  Hazard        -  333 
Those  which  are  in  such  a  State  as  to  be  irreducible  by  the  mere 
Hand,  and  in  which  a  Chirurgical  operation  is  necessary  for  the 

Preservation  of  the  Life  of  the  Patient 341 

Parts  composing  a  Rupture,  when  so  diseased  as  to  be  unfit  for  imme- 
diate Reduction,  what  then  becomes  necessary      -        .        -        -  358 
Ruptures  in  Females         -.-.....-  367 
The  crural  or  femoral  Hernia             -        -        -        -        -        -        -370 

The  congenial  Hernia       --. 372 

The  umbilical  Rupture             ..--.---  376 

The  ventral  Hernia,  &c.            ..-.----  380 

Attempts  toward  a  radical  Cure 382 

Observations  and  Cases  relative  to  Ruptures              ...        -  391 

Intestinal  Herniae 406 

Congenial  Herniae      .....----.  418 

Hernia  Vesicae  Urinarise              -        -        --         -         -        -         -  433 

An  ovarian  Hernia     ....--.---  436 


yoL.  I. 


SHORT  ACCOUNT 


M^  mw 


A  SHORT  ACCOUNT,  ^c. 


At  the  time  of  Mr.  Pott's  decease,  very  few  copies 
of  his  works  remaining  in  the  bookseller's  hands,  I  was 
prevailed  upon  to  superintend  and  publish  a  new  edition 
of  them:  this,  also,  having  been  some  time  since  ex- 
hausted,  a  similar  application  has  been  made  to  me  rC" 
specting  another  edition. 

The  encouraging  reception  of  the  former,  and  the 
high  respect  which  I  must  ever  retain  for  the  author^ 
are  sufficient  inducements  again  to  lend  any  assistance 
in  ,_my  power  to  promote  the  circulation  of  his  valuable 
instructions. 

The  writings  of  Mr.  Pott  had  been  universally  readj 
and  many  of  his  improvements  in  the  practice  of  surgery 
had  come  into  general  use,  for  several  years  before  his 
death.  Most  of  his  opinions  have  stood  the  test  of  ex- 
tensive experience;  and  it  is  hardly  to  be  doubted,  that^ 
whatever  improvements  have  since  been  or  may  here- 
after be  made  in  this  progressive  art,  his  works  will  be 
esteemed  as  a  valuable  monument  of  genius  and  of  skilly 
for  the  times  in  which  the  author  lived,  to  the  latest 
posterity. 

The  event  which  put  a  period  to  the  useful  labours 
of  Mr.  Pott  also  closed  his  account  of  them;  as,  to  the 
great  disappointment  of  the  medical  world,  little  new  oja 


IV  A  SHORT  ACCOUNT  OF  THE 

any  chirurgical  subject  was  discovered  among  tlie  papers 
of  an  author,  whose  pen  was  seldom  long  unemployed. 
This  was  not  the  effect  of  accident  or  inattention,  but 
of  design,  for  the  last  years  of  Mr.  Pott's  life  were  not 
less  industriously  spent  than  the  earlier  part;  nor  was 
the  spirit  of  inquiry  or  of  emulation  at  all  diminished  by 
his  advanced  age,  but  he  had  given  his  friends  every 
reason  to  expect  that  no  manuscript  would  be  left;  and 
often  censured,  in  strong  terms,  the  imprudence  of  au- 
thors leaving  imperfect  papers  behind  them,  which  their 
relations  seldom  have  discretion  or  disinterestedness 
enough  to  suppress.  My  constant  intercourse  with  him, 
both  on  business  and  in  his  leisure  hours,  gave  me  an 
opportunity  of  knowing  his  sentiments  on  some  subjects 
which  had  occurred  since  his  last  publication.  Such  of 
these  as  materially  affected  the  doctrines  he  delivered, 
were  noticed  in  the  last  edition ;  and  have  endeavour- 
ed, in  the  present,  still  further  to  correct,  arrange,  and 
add,  whatever  has  appeared  to  me  likely  to  contribute 
to  tlie  general  usefulness  of  the  work. 

To  my  last  edition  I  prefixed  a  short  historical  ac- 
count of  the  author's  life,  which  I  presume  will  not  be 
unacceptable  to  the  readers  of  this:  the  thoughts,  the 
conduct,  and  actions  of  celebrated  men  have  been  gene- 
rally considered  interesting  and  useful. 

My  near  connexion  with  the  family  of  Mr.  Pott  fur- 
nished me  with  the  most  authentic  information  con- 
cerning every  transaction  of  his  life  whicli  could  in  any 
way  interest  mankind,  and  having  been  already  faithfully 
and  correctly  detailed,  will  be  reprinted  with  very  few 
alterations. 

Percivall  Pott  was  born  on  the  26th  of  December, 
171 S,  in  that  part  of  Threadneedle-street  which  is  now 


LIFE  OF  MR.  POTT.  V 

the  site  of  the  new  Bank-buildings.  His  father,  whose 
Christian  name  was  Percivall,  married  the  widow  of 
Mr.  Houblon,  son  of  Sir  Jacob  Houblon;  and,  in  1717, 
left  her  again  a  widow,  and  him,  their  only  son,  with 
means  very  inadequate  to  their  support.  The  deserted 
state  of  Mrs.  Pott,  joined  with  a  deserving  character, 
and  many  excellent  qualities,  could  not  fail  of  engaging 
the  attention  of  her  friends,  among  wliom  was  Dr.  Wil- 
cox, bishop  of  Rochester,  her  distant  relation,  who  took 
her  son  under  his  immediate  patronage.  Thus  she  was 
enabled  to  pursue  a  plan  for  his  education  and  future 
views  in  life,  which  were  the  principal  objects  of  her 
maternal  sohcitude.  Mr.  Pott  returned  her  tender  care 
with  the  utmost  affection.  Indeed,  so  enthusiastic  was 
his  love  for  his  mother,  so  great  the  obligations  which 
he  always  conceived  he  owed  to  her,  and  so  unimpaired 
by  time  was  his  remembrance  of  them,  that,  to  the  last, 
he  never  mentioned  her,  but  in  terms  expressive  of  sen- 
sibility and  gratitude. 

When  seven  years  old,  he  was  sent  to  a  private  school, 
at  Darne  in  Kent,  where  the  instructions,  though  very 
confined,  were,  to  a  mind  of  his  quick  conception,  suf- 
ficient to  form  an  early  taste  for  classical  knowledge; 
which,  by  his  own  assiduity,  without  further  assistance, 
was  afterwards  improved  to  critical  accm'acy. 

Mr.  Pott  showed,  very  early,  a  strong  propensity  to 
the  profession  of  surgery.  Some  of  his  best  friends  re- 
commended the  church,  in  which  he  had  no  inconsider- 
able prospects  of  preferment;  but  neither  advice  nor 
persuasion  could  alter  his  fixed  determination.  He  was 
accordingly,  in  1729,  bound  an  apprentice  to  Mr. 
Nourse,  one  of  the  surgeons  of  St.  Bartholomew's  hos- 
pital.    In  this  situation  he  had  great  opportunities  of 


Vl  A  SHORT  ACCOUNT    OF  THE 

improvement,  particularly  with  regard  to  anatomy,  which 
was  at  that  time  little  cultivated  in  London.  Mr.  Nourse 
was  one  of  the  few  who  then  gave  anatomical  lectures; 
his  school  w^as  at  London-house,  in  Aldersgate-street; 
and  Mr.  Pott  was  employed  in  preparing  the  subjects 
for  demonstration,  which  laid  the  foundation  of  his  accu- 
rate acquaintance  with  that  science,  the  basis  of  chi- 
I'urgic  knowledge.  In  the  hospital  he  found  unlimited 
opportunities  of  studying  the  nature  and  progress  of  dis- 
eases, and  of  observing  practical  surgery. 

At  that  time  the  art  was  miserably  defective;  the  in- 
struments were  clumsy  and  unmanageable;  the  opera- 
tions unscientific,  and  unnecessarily  painful:  the  esta- 
blished mode  of  practice,  incumbered  with  a  farrago  of 
useless  medicines  and  applications,  tended  rather  to 
mislead  than  direct  the  inquirer;  prescription  too  fre- 
quently held  the  place  of  reason;  and  want  of  real  know- 
ledge was  concealed  under  a  pompous  garb  and  specious 
demeanour.  Though  labouring  under  these  disadvan- 
tages, his  intuitive  genius  soon  led  him  to  discriminate 
between  right  and  wrong,  taught  what  to  adopt,  what 
to  reject;  and  enabled  him  afterwards  to  break  through 
the  trammels  of  prejudice  and  custom.  During  his  ap- 
prenticeship, his  natural  vivacity  did  not  prevent  the 
appli^-^ation  of  a  very  considerable  portion  of  his  time  to 
the  study  of  authors  in  every  branch  of  surgery.  Very 
early  in  life,  he  adopted  Lord  Bacon's  advice  to  a  stu- 
dent, to  consider  one  part  and  one  disease  at  a  time,  and 
to  become  thoroughly  acquainted  with  that  before  he 
undertook  another:  on  that  plan,  he  never  quitted  the 
immediate  object  of  his  inquiry,  till  he  had  traced  it  to 
every  source  of  information. 

Mr.  Pott  always  professed  great  value  and  respect  for 


LIFE    OF    MR.    POTT.  VIJ 

the  early  writers  on  the  art,  and  perused  then*  volumi- 
nous works  with  great  diligence  and  sagacity.  He  fre- 
quently observed,  that  though  no  great  advantage  could 
be  derived  from  them  in  the  practical  part,  yet  whoever 
studied  them  would  be  amply  repaid,  by  their  accurate 
description  of  diseases,  which  they  portrayed  from  na- 
ture. But  his  reading  was  not  confined  to  professional 
books;  it  was  various  and  extensive;  and  I  think  I  may 
venture  to  say,  that  his  memory  never  suffered  any  thing 
to  escape  which  he  had  once  thought  worthy  a  place  in 
his  mind. 

In  1736,  at  twenty-two  years  of  age,  having  finished 
his  apprenticeship,  he  immediately  applied  himself  to 
business.  Confident  in  the  fair  prospects  of  industry, 
he  hired  a  house,  of  considerable  rent,  in  French- 
church-street,  and  took  with  him  his  mother,  and  her 
daughter  by  the  first  husband.  Such  a  young  man 
could  not  long  remain  unnoticed:  the  assistance  which 
is  given  at  the  entrance  into  life  is  most  valuable  and 
most  disinterested.  Of  this  Mr.  Pott  was  perfectly  sen- 
sible, and  always  acknowledged  with  gratitude  the  obli- 
gations which  he  owed  to  the  fostering  favourers  of  his 
youth.  As  the  brilliancy  of  his  talents  brought  his  con- 
versation into  much  request,  his  connexions  were  soon 
universally  extended.  Besides  the  families  to  which  his 
profession  introduced  him,  he  became  acquainted  vi'ith 
most  of  his  cotemporaries  of  rising  and  eminent  abilities 
in  every  profession.  The  early  friendships  which  he 
formed  were  permanent;  and  it  may  truly  be  asserted, 
that  few  men  have  acquired  and  retained  througTX:  life 
more  firm  or  more  respectable  friends. 

In  1744-5,  he  was  elected  an  assistant-surgeon,  and 
in  1749  he  was  appointed  one  of  the  principal  surgeons 


Vlll  A  SHORT  ACCOUNT  OF  THE 

of  St.  Bartholomew's  hospital.  He  had  now  before  him 
sufficient  scope  for  the  exercise  of  those  abihties  by 
which  mankind  have  since  been  so  much  benefited. 
The  state  of  surgery  was  still  very  imperfect,  notwith- 
standing some  sensible  and  ingenious  men,  both  in  this 
country  and  in  France,  had  published  observations  which 
had  enlightened  and  improved  it:  still  the  maxim,  "  Do- 
lor medecina  doloris,"  remained  unrefuted;  the  severe 
treatment  of  the  old  school,  in  the  operative  part  and  in 
the  applications,  continued  in  force;  the  first  principles 
of  surgery,  the  natural  process  and  powers  of  healing, 
were  either  not  understood  or  not  attended  to;  painful 
and  escharotic  dressings  were  continually  employed; 
and  the  actual  cautery  was  in  such  frequent  use,  that, 
at  the  times  when  the  surgeons  visited  the  hospital,  it 
was  regularly  heated  and  prepared  as  a  part  of  the  ne- 
cessary apparatus.  In  the  works  of  several  authors, 
who  flourished  in  the  early  part  of  our  author's  life,  we 
have  contrivances  for  improving  these  dreadful  instru- 
ments. Mr.  Pott's  tutor  rigidly  adhered  to  the  establish- 
ed practice,  and  treated  with  supercilious  contempt  the 
endeavours  of  his  pupil  to  recommend  a  milder  system. 
But  the  dictates  of  truth  soon  found  a  welcome  recep- 
tion with  the  profession,  and  with  the  world  in  general. 
Mr.'  Pott  lived  to  see  these  remains  of  barbarism  set 
aside,  and  a  more  humane  and  rational  plan,  of  which 
he  was  the  chief  author,  universally  adopted.  Surgery, 
being  thus  divested  of  great  part  of  its  horrors,  became, 
comparatively,  a  pleasing  study;  for,  except  on  those 
unfc«itunate  occasions,  when  the  humane  feelings  of  the 
practitioner  must  suffer,  from  the  unavoidable  necessity 
of  giving  pain,  the  aim  and  end  of  the  healing  art  are 
surely  pleasing.     To  possess  the  power  as  well  as  the 


LIFE  OF  MR.  POTT.  IX 

inclination  to  relieve  distress,  to  soften  anguish,  and  in 
some  measure  to  break  the  force  of  those  accidents  and 
misfortunes,  to  which  mankind  are  always  liable,  must 
afford  to  every  feehng  mind  the  greatest  and  most  sin- 
cere pleasure  which  it  is  capable  of  enjoying. 

Mr.  Pott's  affection  for  his  mother  prevented  him 
from  forming  any  attachment  during  her  life,  which 
might  separate  him  from  her.  In  1 746,  being,  to  his 
sorrow,  released  from  this  filial  engagement,  he  remov- 
ed to  Bow-lane,  and  married  the  daughter  of  Robert 
Cruttenden,  Esq.  \  a  lady  of  whom  every  thing  commend- 
able might  justly  be  said,  and  who,  in  mental  and  per- 
sonal accomplishments,  was  formed  to  be  his  compa- 
nion.a 

In  the  year  1756,  an  a;ccident  befel  Mr.  Pott;  which, 
though  of  little  consequence  in  itself,  yet,  as  it  displays 
the  vigour  and  firmness  of  his  mind,  and  seems  to 
have  had  considerable  influence  on  his  future  life, 
deserves  to  be  recorded  in  this  place: — As  he  was 
riding  in  Kent-street,  Southwark,  he  was  thrown  from 
his  horse,  and  suffered  a  compound  fracture  of  the  leg, 
the  bone  being  forced  through  the  integuments.  Con- 
scious of  the  dangers  attendant  on  fractures  of  this  na- 
ture, and  thoroughly  aware  how  much  they  may  be  in- 
creased by  rough  treatment,  or  improper  position,  he 
would  not  suffer  himself  to  be  moved  until  he  had  made 
the  necessary  dispositions.     He  sent  to  Westminster, 

»  I  may  now  add  (1808),  that,  at  the  age  of  86,  Mrs.  Pott  still  retains 
her  excellent  understanding  and  faculties  unimpaired.  In  society,  cheer- 
ful and  interesting,  with  strong  powers  of  recollection  and  judgment,  she 
attracts  around  her  the  young,  the  old,  the  grave,  and  the  gay ;  and,  with 
a  pen  equal  to  that  of  Madame  De  Sevigne,  instructs  and  delights  a  nume» 
rous  set  of  correspondents. 

VOL.  I,  B 


X  A  SHORT  ACCOl/NT  OF  THE 

then  the  nearest  place,  for  two  chairmen,  to  bring  theh' 
poles;  and  patiently  lay  on  the  Qoid  pavement,  it  being 
the  middle  of  January,  till  they  arrived.  In  this  situa- 
tion he  purchased  a  door,  to  which  he  made  them  nail 
their  poles.  When  all  was  ready,  he  caused  himself  to 
be  laid  on  it,  and  was  carried  through  Southwark,  over 
London-bridge,  to  Watling-street,  near  St.  Paul's,  where 
he  had  lived  for  some  time — a  tremendous  distance  in 
such  a  state!  I  cannot  forbear  remarking,  that  on  such 
occasions  a  coach  is  too  frequently  employed,  the  jolting 
motion  of  which,  with  the  unavoidable  awkwardness  of 
position,  and  the  difficulty  of  getting  in  and  out,  cause  a 
great,  and  often  a  fatal  aggravation  of  the  mischief  At 
a  consultation  of  surgeons,  the  case  was  thought  so  des- 
perate as  to  require  immediate  amputation.  Mr.  Pott, 
convinced  that  no  one  could  be  a  proper  judge  in  his 
own  case,  submitted  to  their  opinion;  and  the  instru- 
ments were  actually  got  ready,  when  Mr.  Nourse,  who 
had  been  prevented  from  coming  sooner,  fortunately 
entered  the  room.  After  examining  the  hmb,  he  con- 
ceived there  was  a  possibility  of  preserving  it:  an  at- 
tempt to  save  it  was  acquiesced  in,  and  succeeded.  This 
case,  which  Mr.  Pott  sometimes  referred  to,  was  a 
strong  instance  of  the  great  advantage  of  preventing  the 
insinuation  of  air  into  the  wound  of  a  compound  frac- 
ture; and  it  probably  would  not  have  ended  so  happily, 
if  the  bone  had  not  made  its  exit,  or  external  opening, 
at  a  distance  from  the  fracture;  so  that,  when  it  was  re- 
turned into  the  proper  place^  a  sort  of  valve  was  formed, 
which  excluded  air.  Thus  no  bad  symptom  ensued, 
but  the  wound  healed,  in  some  measure,  by  the  first  in- 
tention.— The  appearance  of  Mr.  Pott  as  an  author 


LIFE  OP  MR.  POTT.  X» 

was  an  immediate  effect  of  this  accident.''  During  the 
leisure  of  his  necessary  confinement,  he  planned,  and 
partly  executed  his  Treatise  upon  Ruptures,  which  was 
completed  by  the  latter  end  of  the  year.  It  was  then 
not  an  early  period  of  his  life:  and  it  is  possible  that  the 
busy  scene  in  which  he  had  hitherto  been  engaged,, 
might  have  occupied  his  mind  much  longer.  As  he 
had  been  thus  led  on  to  the  age  of  forty-three,  it  is  by  no 
means  impossible  that,  without  some  powerful  check  to 
the  train  of  his  pursuits,  he  might  never  have  discovered 
in  himself  those  superior  powers  of  scientifical  disquisi- 
tion, that  correct  taste  and  masterly  command  of  language, 
which  have  placed  him  in  the  first  rank  of  medical  wri- 
ters. Engaged,  from  early  youth,  in  the  constant  trans- 
action of  business,  he  probably  till  this  period  had  in-- 
dulged  but  little  in  the  pleasures  of  speculative  investi- 
gation, but  was  never  afterwards  long  unemployed  in 
some  literary  work.  Indeed,  the  flattering  reception  of 
his  pubhcations,  and  the  gratification  of  communicating 
to  the  world  scientifical  improvements,  would  have  been 
sufficient  to  confirm  a  mind,  less  ambitious  of  fame  than 
hi«,  in  the  habits  of  an  author. 

In  1757  he  wrote  an  account  of  the  Hernia  Congenita, 
a  complaint  not  then  well  understood.  Dr.  William 
Hunter,  the  celebrated  anatomist,  who  was  engaged  in 
the  same  pursuit,  inserted  a  paper  in  the  Medical  Com- 
mentaries, claiming  a  priority  in  the  discovery.  But  I  da 
not  mean  to  enter  into  the  merits  of  a  dispute,  which, 

•>  I  do  not  find  that  Mr.  Pott  had  written  any  thin^-  previous  to  this,  ex- 
cept the  relation  of  a  curious  case  of  tumours,  by  which  the  bones  were 
softened.  This  was  presented  to  the  Royal  Society  soon  after  he  began 
business,  and  may  be  found  in  the  2d  part  of  the  41st  volume  of  the  Philo- 
sophical Transactions. — It  is  also  inserted  at  the  end  of  the  2d  Vol.  of  these 
Works. 


XU  A  SHORT  ACCOUNT  OP  THE 

though  at  that  time  it  caught  the  attention  of  the  medi- 
cal world,  is  now  nearly  forgotten.  Mr.  Pott's  reply 
was  inserted  in  the  second  edition  of  his  Treatise  on 
Ruptures,  and  is  written  with  elegance  and  urbanity. 

His  observations  on  the  disorder  of  the  corner  of  the 
eye,  commonly  called  Fistula  Lachrymalis,  appeared  in 
1758.  This  sensible,  well  written  performance  on  a 
complaint  which  frequently  occurs,  has,  both  in  matter 
and  manner,  considerable  merit.  In  it  he  explains  the 
situation,  describes  the  various  appearances  of  the  dis- 
ease, and  simplifies  the  method  of  cure:  his  arguments 
were  the  principal  cause  of  discontinuing  the  operation 
by  the  actual  cautery,  which  was  practised  and  recom- 
mended by  Mr.  Chesselden,  who  flourished  in  the  early 
part  of  our  author's  hfe. 

In  1760  was  produced  his  elaborate  performance  on 
the  nature  and  consequences  of  wounds  and  contusions 
of  the  head,  fractures  of  the  scull,  concussions  of  the 
brain,  &c.  in  which,  with  a  perspicuity  till  then  un- 
known, he  separates  and  arranges  the  symptoms  of  each 
particular  species  of  injury,  unfolds  the  causes  and  situ- 
ation of  mischief,  and  points  out  the  most  probable 
means  of  relief. 

In  1 162  he  published  Practical  Remarks  on  the  Hy- 
drocele, and  some  other  diseases  of  the  testis,  its  coats, 
and  vessels,  illustrated  with  cases;  being  a  supplement 
to  his  general  Treatise  on  Ruptures. 

In  1764  he  had  the  honour  to  be  elected  a  Fellow  of 
the  Royal  Society;  at  the  same  time,  he  presented  them 
with  a  curious  and  uncommon  case  of  a  hernia  of  the 
urinary  bladder,  including  a  stone,  which  is  inserted  in 
the  Philosophical  Transactions,  Vol.  LIV.;  and  also  at 
the  end  of  these  volumes. 


LIFE  OF  MR.  PO.TT.  XUl 

As  the  activity  of  Mr.  Pott's  mind  was  equal  to  his 
zeal  for  the  advancement  of  the  art,  wliatever  subject 
appeared  to  him  to  have  been  least  considered,  or  most 
defectively  treated  by  others,  immediately  became  the 
object  of  his  researches,  and  engaged  his  particular  at- 
tention. The  fistula  in  ano  next  attracted  his  notice. 
The  nature  of  this  complaint  had  been  much  mistaken, 
and  the  operations  for  its  relief  vt^ere  consequently  inju- 
dicious, horridly  severe,  and  destructive  of  the  parts 
they  vi^ere  intended  to  relieve.  In  1765  he  published  a 
treatise  on  this  subject.  His  method  of  reasoning  on  it 
is  clear,  ingenious,  and  conclusive;  but  they  only  can 
be  judges  of  this  inestimable  work  who  have  compared 
the  simple  operation  which  it  recommends  with  those 
usually  practised  in  similar  cases  in  this  kingdom,  until 
the  latter  part  of  Mr.  Pott's  life,  and  even  at  the  present 
time  in  other  countries. 

The  observations  and  instructions  which  thus  flowed 
from  his  ready  pen,  were  enforced  by  his  practice,  and 
illustrated  by  oral  communication;  and  he  was  happy  to 
embrace  every  opportunity  which  his  situation  gave  him, 
of  conveying  the  information  he  had  collected  to  those 
w^ho  had  not  the  same  means  of  acquiring  it. 

The  humane  and  benevolent  disposition  of  the  people 
of  this  country  is  eminently  displayed  in  the  many  cha- 
ritable institutions  which  abound  for  the  relief  and  pro- 
tection of  the  poor,  and  in  the  ample  support  of  them. 
The  beneficial  influence  of  hospitals  is  not  shut  up 
within  their  walls,  nor  confined  to  the  objects  who  are 
there  relieved;  the  blessings  which  are  there  distributed 
revert  to  their  opulent  and  noble  supporters,  and  are 
extended  to  all  ranks  and  conditions  of  men,  by  the  im- 
provements which  the  medical  art  receives  from  the  stii- 


XIV  A  SHORT  ACCOUNT  OF  THE 

dents  who  frequent  them.  In  a  large  hospital  there 
must  be  opportunities  of  seeing  the  greatest  possible  va- 
riety of  diseases,  such  as  are  either  produced  or  increas- 
ed by  negligence  and  intemperance,  added  to  those 
which  are  met  with  among  the  more  prudent  and  better 
informed  part  of  mankind.  In  short,  all  the  multiform 
deviations  from  health  and  natural  perfection  are  there, 
as  in  one  large  volume,  collected  and  displayed.  Of 
the  advantages  arising  from  such  a  collection,  no  person 
could  be  more  sensible  than  Mr.  Pott;  but  he  also  judi- 
ciously remarked,  that  young  men  often  stood  in  need 
of  an  index  to  point  out  to  them  the  proper  objects  for 
their  attention  and  inquiry.  To  supply  the  deficiency, 
about  this  time  he  instituted  a  course  of  lectures,  the 
first  of  which  was  given  at  his  house  in  Watling-street. 
He  had  not  then  digested  and  arranged  his  ideas,  but 
spoke,  as  I  well  remember,  with  hesitation  and  reserve: 
yet  even  these  his  first  essays  bore  strong  marks  of  his 
comprehensive  and  penetrative  mind.  In  a  few  courses 
he  overcame  all  obstacles,  and  communicated  his 
thoughts  with  eloquence  and  ease.  He  was  not  satis- 
fied with  following  any  system  which  had  been  laid 
down  by  others,  as  he  thought  they  in  general  dwelt  too 
much  on  the  operative  part,  which,  though  veiy  impor- 
tant, is  by  no  means  the  most  difficult  part  of  surgery, 
nor  the  most  worthy  of  attention.  The  means  of  pre- 
venting the  necessity  of  operations,  he  observed,  should 
be  the  first  consideration;  he  therefore  formed  a  plan  of 
his  own,  the  best,  perhaps,  which  could  be  devised.  He 
began  with  such  general  disorders  as  may  affect  any 
part  of  the  human  frame,  and  afterwards  proceeded  to 
consider  the  diseases  of  each  part  distinctly,  beginning 
with  the  head,  and  descending  to  the  inferior  members. 


LIFE  OF  MR.  POTT.  XV 

He  took  great  pains  on  every  point;  and,  having  the  art 
of  being  minute  without  tediousness,  demonstrated  it 
with  clearness  and  precision.  His  manner  gave  impor- 
tance to  every  subject,  and  impressed  his  audience  with 
the  idea,  that  the  art  which  he  taught  was  worthy  of 
their  highest  ambition.  He  not  only  explained  the  best 
modern  practice  with  his  own  observations,  but  ren- 
dered the  lecture  still  more  curious  and  interesting,  by 
a  review  of  the  practice  of  the  ancients,  and  of  the  gra- 
dual progress  of  improvement  which  had  taken  place. 

This  his  extensive  perusal  of  authors  of  all  ages  had 
made  easy  to  him;  for  there  was  no  time  of  his  life  when 
he  thought  so  highly  of  himself  as  to  imagine  that  he 
could  receive  no  light  from  books.  He  often  said,  he 
began  to  teach  when  he  had  much  to  learn;  and,  as  he 
was  not  actuated  by  that  opinionative  wisdom  which 
sometimes  attends  advanced  hfe,  after  all  his  study  and 
experience  he  confessed,  that  he  still  retained  a  long 
list  of  inquirenda.  His  lectures  were  constantly  at- 
tended by  a  numerous  succession  of  pupils,  and  have 
been  the  means  of  very  extensively  disseminating  much 
useful  knowledge. 

In  1 768  he  produced  a  new  edition  of  his  book  on 
the  Injuries  to  which  the  Head  is  liable  from  External 
Violence,  accompanied  with  what  is  entitled  A  Few 
General  Remarks,  but  which  is  really  a  complete  sys- 
tem on  fractures  and  dislocations.  This,  I  have  been 
informed,  he  began  and  completed  in  a  fortnight.  The 
novelty  of  the  doctrine  contained  in  this  treatise  relates 
principally  to  the  position  of  the  injured  limb.  On  its 
publication  it  met  with  some  opposition,  but  has  now 
subdued  the  first  prejudices;  and  I  beheve  I  may  ven- 
ture to  say,  is  become  almost  the  universal  practice. 


XVI  A  SHORT  ACCOUNT  OP  THE 

The  frequent  avocations  of  Mr.  Pott  towards  the  west 
end  of  the  town,  where  the  buildings  had  prodigiously 
increased  since  he  began  life^  making  a  more  central 
situation  necessary,  in  1769  he  purchased  a  house  near 
Lincoln's-inn  Fields,  and  resided  in  it  seven  years,  dur- 
ing which  time  his  pen  was  not  inactive.  The  hydro- 
cele again  employed  his  thoughts.  In  1772  he  sent  to 
the  press  his  improved  method  of  passing  the  seton,  so 
as  not  to  rub  or  injure  the  gland  in  its  passage. 

Mr.  Pott  took  great  pains  with  this  subject,  and 
never  was  perfectly  satisfied  with  what  he  had  done  in 
it.  Various  other  methods  have  been  employed  for  the 
cure  of  this  complaint,  and  practitioners  are  still  divided 
between  them.  I  must  confess  that  the  curative  inten- 
tion does  not  seem  well  answered  by  either  of  them: 
they  all  appear  to  me  to  raise  more  inflammation,  and  to 
derange  the  economy  of  those  tender  and  sensible  parts 
more  than  is  necessary.  I  have  proposed  another,  which 
answers  the  purpose  in  a  milder  and  better  manner  than 
any  I  have  yet  seen;  and  I  feel  a  satisfaction  in  saying, 
that  it  met  with  Mr.  Pott's  approbation.  One  of  our 
last  conversations  was  on  this  subject;  and,  if  his  life 
had  been  prolonged,  it  was  his  intention  to  have  prac- 
tised it. 

In  1775,  Mr.  Pott  published  Chirurgical  Observa- 
tions relative  to  the  cataract,  the  polypus  of  the  nose, 
the  cancer  of  the  scrotum,  the  different  kinds  of  rup- , 
tures,  and  the  mortification  of  the  toes  and  feet,  which 
were  valuable  additions  to  his  former  publications,  and 
were  marked  with  that  spirit  of  observation,  perspicuity 
of  reasoning,  and  candour  in  discussing  controverted 
points,  which  distinguish  his  other  productions. 

In  1777  he  removed  to  Hanover-square.     Here,  at 


LIFE  OF  MR.  POTT.  XVU 

an  age  when  most  men  begin  to  think  of  ease  and 
retirement,  his  active  mind  led  him  into  a  scene  more 
busy  and  extensive  than  ever.  Sir  Cassar  Hawkins, 
who  had  long  been  employed  in  many  of  the  first  fami- 
lies, retired  from  London,  which  made  no  inconsiderable 
addition  to  Mr.  Pott's  former  connexions.  But,  though 
engaged  in  business  by  day,  and  occupied  at  home  in 
the  evening,  in  answering  letters  addressed  to  him  from 
all  parts  of  Europe,  I  might  say  of  the  world,  having 
seen  many  letters  in  which  he  was  consulted  on  cases 
from  America,  Russia,  Turkey,  and  India,  as  well  as 
from  our  neighbouring  kingdoms,  he  contrived  to  find 
time  to  add  to  his  former  w^orks  a  treatise  on  the  ne- 
cessity of  amputation  in  certain  cases,  in  which  he  ar- 
gues strongly  in  favour  of  truth  and  humanity,  and 
clearly  proves  the  rectitude  of  the  principles  which  he 
has  laid  down.  This  seems  principally  to  have  been 
written  in  answer  to  Mr.  Bilguer,  surgeon  to  the  army 
of  the  late  King  of  Prussia,  who  had  pubhshed  against 
the  necessity  of  amputating  in  almost  any  case.  The 
title  of  his  book  is,  "De  Membrorum  Amputatione 
"rarissime  administranda,  aut  quasi  abroganda;^^  and 
also,  in  reply  to  his  commentator,  Mr.  Tissot,  who 
wrote  a  treatise,  "  Sur  I'Inutilitt;  de  TAmputation  des 
"  Membres,'"  in  which  he  goes  even  beyond  his  origi- 
nal, and  absolutely  sets  aside  the  operation  as  useless; 
he  speaks  of  it  in  the  most  opprobrious  terms;  he  is 
shocked  at  the  horror  of  it;  exhorts  surgeons  to  aban- 
don the  murderous  and  cruel  method  of  amputation, 
with  many  other  expressions  equally  misapplied.  Such 
futile  and  absurd  imputations  can  never  confute  what 
reason  and  experience  have  joined  to  demonstrate,  that 
many  Hves  have  been  saved  by  the  operation,  which 
VOL.  r.  c 


XVllI  A  SHORT  ACCOUNT  OP  THE 

would  otherwise  have  been  infalhbly  lost.  However, 
as  we  must  suppose  that  the  doctrine  which  these  gen- 
tlemen have  promulgated  arose  from  humane  motives, 
and  upon  a  conviction  of  its  being  well  founded,  we 
must  at  least  applaud  their  intention,  though  we  cannot 
approve  their  judgment.  But  if  it  were  possible  that 
any  man  could  be  found  capable  of  writing  in  defence 
and  support  of  the  unfeeling  doctrine,  that  mutilated 
men  are  a  burthen  to  the  state,  and  that  it  is  cheaper  to 
enlist  men  than  to  cure  them,  such  a  work  would  de- 
serve to  be  reprobated,  and  the  author's  name  to  be 
consigned  to  the  detestation  of  posterity. 

In  1779,  Mr.  Pott  pubhshed  his  Remarks  on  that 
kind  of  palsy  of  the  limbs  which  is  frequently  found  to 
accompany  a  particular  curvature  of  the  spine.  He  in- 
troduced his  first  treatise  on  this  subject  with  doubts 
and  surmises,  having  just  drawn  the  outline;  but,  find- 
ing his  opinion  confirmed  by  experience,  he  with  confi- 
dence produced  his  further  remarks  on  this  disease,  in 
1783,  in  which  he  gives  a  complete  description  of  the 
complaint,  so  little  understood  before,  that  those  wh© 
suffered  under  it  were  consigned  to  their  fate,  which 
usually  led  to  inactivity,  deformity,  and  death.  In  this 
valuable  tract  he  lays  down  a  very  accurate  discrimina- 
tion of  this  from  every  other  species  of  paralysis,  and 
proposes  a  new  and  most  efficacious  method  of  stopping 
its  progress,  and  curing  it. 

This  was  the  last  of  his  literary  productions:  the 
mode  of  cure  which  he  recommends  in  it  he  afterwards 
applied  to  diseases  of  the  hip-joint,  with  considerable 
Success.  If  his  life  had  fortunately  been  prolonged,  it 
was  his  intention  to  pubhsh  his  opinions  on  this  subject. 
At  the  same  time,  I  have,  great  reason  to  think  he  would 


LIFE  OF  MR.  POTT.  XIX 

iiave  added  an  account  of  those  very  painful  excres- 
cences which  are  frequently  the  consequence  of  long- 
neglected  piles.  He  had  been  remarkably  succes'^ful  in 
the  treatment  of  this  afllicting  complaint,  and  thought 
the  disease  itself  not  sufficiently  understood,  nor  the 
mode  by  which  he  succeeded  commonly  practised;  but, 
as  it  was  not  his  custom  to  begin  to  write  on  any  sub- 
ject till  he  was  prepared  to  finish  it,  it  is  to  be  lamented 
that  his  ideas  on  these  and  some  other  important  points 
were  not  committed  to  paper.  As  Mr.  Pott  conceived 
these  subjects  to  be  of  so  much  importance,  I  cannot 
pass  them  over  in  silence,  though  I  much  regret  that 
they  have  not  been  laid  before  the  public  in  his  compre- 
hensive manner.'' 

The  time  now  began  to  approach  when  Mr.  Pott  may 
be  said  to  have  attained  the  summit  of  that  eminence 
which  he  owed  to  himself  alone.  Though  unadorned 
with  any  honorary  distinction  in  the  profession,  he  was 
sought  after  and  employed  by  persons  in  the  first  degreed 
of  rank  and  power;  and  though  he  solicited  neither 
honours  nor  favours  for  himself,  he  often  successfully 
employed  his  influence  on  behalf  of  others.  He  was 
universally  consulted;  practitioners  referred  to  him  in 
cases  of  uncommon  difficulty  and  danger,  as  their  last 
resource;  his  extensive  experience,  and  his  ready  appli- 
cation of  it,  rendered  that  easy  to  him,  which,  to  most 
other  men,  would  have  been  a  painful  pre-eminence. 

The  Royal  College  of  Surgeons  in  Edinburgh  were 
not  inattentive  to  his  deserts.  In  1 786  he  received  a 
diploma,  accompanied  by  a  letter  expressive  of  the  sense 
they  entertained  of  them:  the  value  of  the  honour  was 

"i  vide  Vol.  n. 


XX  A  SHOUT  ACCOUNT  OF  THE 

greatly  enhanced  by  his  being  the  first  person  on  whom 
they  had  thought  proper  to  bestow  it.*" 

In  the  following  year  the  Royal  College  of  Surgeons 
in  Ireland  presented  him  with  their  freedom,  in  a  silver 
box/ 

In  July  1787  he  resigned  the  office  of  Surgeon  to  St. 
Bartholomew's  hospital,  after  having  served  it,  as  he 
used  to  say,  man  and  boy,  half  a  century.  On  the  day 
of  his  resignation,  the  annual  meeting  of  the  governors 
was  held,  and  they  dined  in  the  great  room  of  the  hospi- 
tal: when  he  w^as  about  to  retire,  the  Right  Honourable 


=(COPY.) 
"  SIR,  Edinburifh,  Aug.  1,  1786. 

"  It  is  with  peculiar  pleasure  I  obey  the  commands  of  the  Royal  College 
of  Surgeons  in  acquainting  you,  that  they  have  this  day  unanimously  elected 
you  an  Honorary  Fellow  of  the  Royal  College  of  Surgeons  of  Edinburgh,  a 
compliment  which  they  think  your  very  distinguished  merit  justly  enti- 
tied  to. 

"  May  I  add,  as  an  additional  mark  of  the  College's  respect,  that  you  are 
the  first  Gentleman  of  the  Faculty  they  have  thought  proper  to  bestow  the 
honour  on. 

"  I  have  the  honour  to  be,  &c. 

"THOMAS  HAY,  President." 


f(COPY.) 
"  HONORARY  DIPLOMA 

"  Voted  to  Fercivali.  Pott,  Esq.  Sept.  9th,  1787,  by  the  Royal  College  of  Sur^ 
geons  in  Ireland. 
"  Whereas  it  has  appeared  to  us,  in  full  College  duly  assembled,  that  Per- 
civall  Pott,  Esq.  lias  eminently  distinguished  himself  in  the  science  of  sur- 
gery; now,  we  being  desirous  to  manifest  our  approbation  of  conspicuous 
merit,  do,  by  virtue  of  the  powers  vested  in  us  by  his  majesty's  royal  charter, 
by  these  presents,  elect,  constitute,  and  appoint,  the  said  P.  Pott  an  Hono- 
rary Member  of  this  College,  with  all  the  privileges,  dignities,  and  immunities 
thereunto  annexed. 

(Signed)  «  J.  WHITEWAY,  President." 


LIFE  OF  MR.  POTT.  ^  XXI 

Thomas  Harley,  president,  proposed  a  health  to  Mr. 
Pott,  with  many  thanks  for  his  long,  able,  and  faithful 
services  to  that  house;  which  was  received  with  reitera- 
ted bursts  of  applause.  Mr.  Pott's  usual  readiness  for- 
sook him  on  this  trying  occasion:  after  repeatedly  ris- 
ing to  thank  the  assembly  for  the  compliment  they  had 
paid  him,  he  felt  himself  obliged  to  sit  down  in  silence. 
His  resolution  and  presence  of  mind,  though  not  easily 
overcome,  were  not  proof  against  the  powerful  emo- 
tions excited  by  this  public  and  unexpected  testimony 
of  his  having  acted  well,  and  filled  an  important  station 
to  the  advantage  of  mankind. 

It  is  possible  that  some  of  the  greatest  blessings  we 
enjoy,  may,  by  a  fortuitous  concatenation  of  events,  tend 
to  shorten  their  own  existence.  Thus  it  seemed  in  the 
case  of  Mr.  Pott,  whose  remarkable  temperance  had  in- 
sured him  so  long  a  continuance  of  health  and  spirits, 
that  he  was  deceived  in  himself.  Had  he  been  subject 
to  some  of  the  infirmities  which  usually  attend  people 
of  his  age,  as  he  must  necessarily  have  paid  more  atten- 
tion to  his  general  health,  his  days  might  possibly  have 
been  prolonged.  Though  he  was  free  from  any  parti- 
cular complaint,  and  his  constitution  was  sound,  still  it 
sustained  the  weight  of  more  than  threescore  years  and 
ten!  to  this  his  mind,  busy  and  cheerful  as  ever,  would 
not  permit  him  to  advert.  It  is  painful  to  relate,  that,  in 
the  full  possession  of  his  faculties,  with  a  frame  of  body 
apparently  calculated  to  last  much  longer,  he  fell  a  sa- 
crifice to  his  own  active  disposition,  and  inattention  to 
the  first  attack  of  his  disorder. 

On  Thursday,  11th  December,  1788,  he  went,  in 
very  severe  weather,  to  visit  a  patient  about  twenty  miles 
from  London:  when  he  returned,  he  complained  that 


XXll  A  SHORT  ACCOUNT  OF  THE 

he  had  caught  a  cold.  The  next  day  he  lay  in  bed,  a 
circumstance  very  uncommon  to  him;  the  following  day, 
thinking  himself  better,  he  would  not  submit  to  the  re- 
gimen which  had  been  recommended,  but  went  out  as 
usual;  the  day  after  (Sunday  the  14th)  the  cold  was  re- 
markably intense,  and  it  being  necessary  to  repeat  the 
visit  in  the  country,  I  was  happy  to  save  him  so  incle- 
ment a  journey;  but,  at  my  return,  was  informed  that 
he  had  been  a  round  of  visits  in  town,  and  was  just 
got  home,  perceiving  himself  unable  to  complete  his  list. 
A  shivering  soon  seized  hiui,  and  he  went  to  bed;  a  fe- 
ver succeeded,  and  before  night  he  grew  delirious.  He 
passed  great  part  of  the  night  in  this  state;  the  next 
morning,  on  my  asking  how  he  found  himself,  after  a  short 
apparent  struggle  for  recollection,  the  words  of  his  an- 
swer precisely  were: — "My  mind  has  great  propensity 
"to  aberration;  and  I  find  myself  much  inchned  to 
"  talk  nonsense,  unless  I  studiously  collect  my  thoughts, 
"  and  fix  them." — Through  the  whole  of  his  illness, 
during  the  intervals  of  reason,  his  observations  on  many 
subjects  were  remarkably  sensible  and  pointed;  and  he 
seemed  particularly  attentive  to  correctness  in  his  lan- 
guage. The  description  of  the  pain  he  felt  was  anato- 
mically exact.  He  did  not  appear  to  doubt  of  his  reco- 
very during  several  days,  though  the  fever  continued, 
with  unremitting  violence,  in  opposition  to  the  best  me- 
dical assistance,  being  attended  with  the  most  affectio- 
nate assiduity,  by  the  late  Dr.  Heberden,  Sir  Francis 
Millman,  and  the  late  Dr.  Austin.  His  head  became 
lather  more  clear  as  the  disorder  advanced,  and  he 
seemed  more  sensible  of  his  danger;  on  the  seventh  day 
he  observed,  "  My  lamp  is  almost  extinguished;  I  hope 
•■  it  has  burned  for  the  benefit  of  others."  On  the  fol- 
lowing day,  the  22 d  of  December,  he  expired. 


LIFE  OF  MR.  POTT.  XXlll 

His  remains  were  attended  by  many  of  his  relations 
and  friends  to  Aldermary  church  in  Bow-lane,  where 
they  were  deposited  near  those  of  his  beloved  mother. 

On  a  marble  tablet  affixed  to  the  wall  is  the  following 
inscription,  by  his  son  the  Rev.  Joseph  Holden  Pott, 
A.  M.  Archdeacon  of  St.  Alban's,  &c. 


In  Memory 

Of  PERCIVALL  POTT,  Esq.  F.  R.  S. 

Surgeon  of  St.  Bartholomew's  Hospital  during  Forty-two  Years, 
Who  departed  this  Life,  December  22d,  1788,  aged  75. 

He  was 

Singularly  eminent  in  his  Profession, 

J'o  which  he  added  many  new  Resources,  and  which  he  illustrated 

With  matchless  Writings. 

Let  Posterity  revolve  the  Sum  of  his  Experience, 

That  the  World  may  still  enjoy  the  Benefit  of  his 

Successful  Practice. 

He  honoured  the  collective  Wisdom  of  past  Ages  : 

The  Labours  of  the  Ancients  were  familiar  to  him : 

He  scorned  to  teach  a  Science  of  which  he  had  not  traced  the  growth  ; 

He  rose,  therefore,  from  the  Form  to  the  Chair. 

Learn,  Reader,  that  the  painful  Scholar  can  alone  become 

The  Faithful  Teacher. 

But  his  Studies  had  a  double  Issue : 

Whilst  he  gathered  the  Knowledge  of  his  Predecessors^ 

He  perceived  their  Errors,  and  corrected  them; 

He  discovered  their  Defects,  and  supplied  them. 

Original  In  Genius,  prompt  in  Judgment,  rapid  in  Decision, 

He  directed  Knowledge  to  its  proper  Ends ; 

But  pursued  them  when  the  Aids  of  Information  were  exhausted ; 

The  last  Steps,  therefore,  and  great  Improvements, 

Were  his  own. 

His  Integrity  is  before  his  Judge ; 

Without  it,  his  Skill  might  have  profited  Mankind, 

T*,ut  could  have  claimed  no  Record  within  these  Walls: 

His  private  Virtues, 

His  signal  Tenderness  to  his  Family, 

Completed  an  F.xample, 

Amiable,  Useful,  Great, 


XXIV  A  SHORT  ACCOUNT  OF  THE 

The  genius  of  Mr.  Pott,  however  assisted  by  art,  was 
certainly  of  the  first  order  by  nature,  as  appears  by  the 
variety  and  perfection  of  his  attainments.  He  was  the 
most  eminent  of  his  time  as  a  writer,  as  a  teacher,  and 
as  a  practitioner  in  surgery;  and  his  merits  in  each  of 
these  characters  were  most  extensive.  Possessed  with 
an  enthusiastic  love  of  excelling,  without  which  genius 
is  inert,  he  was  not  contented  with  any  kind  of  medi- 
ocrity in  himself 

As  an  author,  his  language  is  correct,  strong,  and 
animated.  There  are  few  instances,  if  any,  of  such 
classical  elegance,  united  with  so  much  profound  scien- 
tifical  acuteness.  In  his  surgical  inquiries  he  studiously 
avoided  reference  to  obscure  and  general  principles;  he 
preferred  reasoning  by  analogy  and  induction  from  esta- 
blished facts;  a  method  certainly  more  safe  and  more 
accommodated  to  the  present  state  of  physiological 
knowledge.  He  introduces  anatomy  and  physiology, 
whenever  it  is  necessary,  to  illustrate  and  distinguish 
diseases;  but  never  confuses  his  reader  with  uncertain 
hypothesis  in  pathology,  founded  on  physiological  prin- 
ciples. He  was  of  opinion,  and  it  is  the  opinion  of 
Newton,  that  hypothesis  has  no  place  in  any  physical 
science.  To  place  the  disease  in  a  distinct  point  of 
view;  to  demonstrate  wherein  it  consisted,  and  the 
changes  which  must  be  effected  to  remove  it;  to  point 
out  the  remedies  which  would  most  safely  and  certainly 
produce  those  changes,  were  the  objects  to  which  he 
directed  his  whole  attention.  His  remedies  always 
strongly  marked  his  intention;  they  were  decided  and 
consistent;  and  he  w^as  the  principal  author  of  that  sim- 
plicity which  distinguishes  the  present  practice  from 


LIFE  OF  MR.  POTT.  XXV 

that  of  our  ancestors.  With  these  views  he  apphed 
himself  to  every  part  of  the  surgical  art,  and  improved 
both  the  pathology  and  cure  of  many  diseases.  His 
treatment  of  fistulous  sores,  and  his  history  and  cure  of 
the  caries  of  the  corpora  vertebrarum,  were,  perhaps, 
his  greatest  works:  but  his  improvements,  as  we  have 
seen,  extended  to  many  other  subjects;  and  his  re- 
searches introduced  such  novelties  in  the  practice  of 
surgery,  that  his  life  must  ever  be  considered  as  a  great 
epoch  in  the  history  of  that  art. 

As  a  teacher,  he  had  acquired  the  faculty  of  speaking 
readily,  with  great  point  and  energy,  of  delivering  the 
most  prolix  and  intricate  sentences  with  incredible  pers- 
picuity and  correctness,  and  of  enforcing  what  he  said 
with  a  most  harmonious  and  expressive  elocution.  He 
allowed  no  excuse  for  defects  in  himself;  he  always 
avowed  that  excellent  maxim, — 

-Cui  lecta  potenter  erit  res, 


Nee  facundia  deseret  hunc,  nee  lucidus  ordo. 

As  a  practitioner  in  surgery,  we  must  apply  to  him 
all  the  essential  qualifications,  sound  judgment,  cool  de- 
termination, and  great  manual  dexterity.  He  had  seen 
much  of  practice,  and  what  he  had  seen  he  had  digest- 
ed, by  reading,  writing,  and  lecturing  on  those  sub- 
jects. 

In  the  transaction  of  business  there  was  a  freedom 
and  openness  in  his  manner,  which  evidentiy  arose  from 
a  consciousness  that  the  opinion  which  he  delivered  was 
founded  on  experience.  In  every  instance  he  shunned 
affectation  and  singularity;  and  his  conduct  in  all  situ- 
ations was  an  appeal  to  the  good  sense  of  mankind. 

VOL.  I.  D 


XXVI  A  SHORT  ACCOUNT  OF  THE 

Thus  he  acquired  the  universal  confidence  of  the  pro- 
fession; and,  without  any  accidental  or  external  help, 
he  raised  himself  to  the  greatest  dignity  which  man  can 
attain — the  first  rank  in  a  liberal  profession. 

Domestic  virtues  make  no  great  figure  in  history; 
yet  the  domestic  virtues  of  distinguished  men  should  not 
be  forgotten,  because  they  promote  the  cause  of  virtue; 
besides,  great  and  amiable  quahties  reflect  lustre  on 
each  other.  The  ambition,  the  industry,  and  enterprise 
of  Mr.  Pott,  did  at  no  time  interfere  with  the  duties  of 
a  husband  and  a  father.  Though  his  ready  wit  and 
brilhant  conversation,  abounding  with  interesting  anec- 
dotes of  his  own  observation,  and  with  happy  quotations 
from  modern  and  ancient  authors,  rendered  him  a  con- 
spicuous character  in  all  parties,  he  was  most  happy, 
and  not  less  to  be  admired,  in  the  circle  of  his  family. 
In  their  society,  he  spent  much  the  greater  part  of  his 
leisure  hours,  and  in  such  a  manner  as  to  be  the  object 
of  the  utmost  affection  and  veneration  to  a  numerous 
offspring  of  children  and  grand-children. 

The  person  of  Mr.  Pott  was  elegant,  though  lower 
than  the  middle  size;  his  countenance  animated  and 
expressive;  his  manners  and  deportment  were  graceful; 
and  his  remarkable  vigour  and  activity  seemed  unabated 
by  age. 

The  labours  of  the  greatest  part  of  his  life  were  with- 
out relaxation; — an  increasing  family  required  his  ut- 
most exertion.  Of  late  years  he  had  a  villa  at  Neasden; 
and  in  the  autumn  usually  passed  a  month  at  Bath,  or 
at  the  sea-side.  Thus,  though  he  gathered,  as  he  ex- 
pressed it,  some  of  the  fruit  of  the  garden  which  he  had 
planted  as  he  went  along,  and  always  lived  in  a  generous 


LIFE    OF    MR,    POTT.  XXVU 

and  hospitable  manner,  at  the  same  time  bestowing  on 
four  sons  and  four  daughters  a  hberal  and  necessarily 
expensive  education,  and  applying  large  sums  to  their 
establishment  during  his  life-time,  he  left  an  ample  pro- 
vision for  them  at  his  decease.  Among  his  papers  was 
found,  what  he  had  often  mentioned,  a  small  box,  con- 
taining a  few  pieces  of  money,*  being  the  whole  which 
he  ever  received  from  the  wreck  of  his  father's  fortune. 
With  this  was  deposited  an  exact  account  of  every  indi- 
vidual fee  which  a  long  life  of  business  had  produced — 
abundant  evidence  of  well-spent  time,  and  the  indus- 
trious application  of  abilities,  to  which  the  res  angusta 
domi,  at  the  commencement,  probably  acted  more  pow- 
erfully as  an  incentive  than  as  an  obstacle. 

J.  E. 

Hanovei"- Square,  January  1st,  1808. 


*  Under  51. 


MATURE  AKD  COJSrSEQUEJSrCES 


INJURIES 


TO    WHICH 


THE  HEAD  IS  LIABLE 


EXTERNAL  VIOLENCE. 


SECT.  I. 


WOUNDS  OF  THE  SCALP. 


PREVIOUS  to  an  account  of  such  wounds  and  injuries  of  the 
head  as  interest  the  scull,  the  brain,  and  its  membranes,  it  may 
not  be  amiss  to  take  some  small  notice  of  those  to  which  the  scalp 
is  liable.  Though  this  be  called  the  common  tegument  of  the 
head,  yet,  from  the  variety  of  parts  of  which  it  is  composed,  from 
their  structure,  connexions,  and  uses,  injuries  done  to  it  by  external 
violence  become  of  much  more  consequence  than  the  same  kind 
of  ills  can  prove  when  inflicted  on  the  common  teguments  of  the 
rest  of  the  body. 

The  covering,  called  the  scalp,  consists  of  the  cutis,  the  mem- 
brana  adiposa,  or  cellularis,  the  expanded  tendons  of  the  frontal, 
occipital,  and  temporal  muscles,  (forming  a  kind  of  aponeurosis,) 
and  the  membrane  which  immediately  covers  the  bones  of  the 
scull,  called  therefore  the  pericranium. 

This  variety  of  parts,  upon  the  infliction  of  wounds,  blows,  &c. 
frequently  occasions  a  variety  of  symptoms;  which  symptoms 
ought  by  practitioners  to  be  carefully  and  properly  distinguished 
from  each  other;  not  only  because  they  often  arise  from  the  dis- 
tinct and  particular  nature  of  the  part  injured,  but  because  they 
generally  point  out  the  most  eifectual  means  of  relief.  If  to  these 
considerations  we  add  another,  no  less  true  and  important,  viz. 
that  there  is  and  must  be  a  constant  communication,  by  means  of 
blood-vessels,  between  all  the  parts  without  and  within  the  head, 
it  will  appear,  that  injuries  done  to  this  part,  though  seemingly, 
and  at  first  sight,  slight  and  trivial,  may  sometimes  prove  of  the 
greatest  consequence. 

I  will  not  waste  the  reader's  time,  by  entering  into  a  detail  of 


3^  INJURIES  OF  THE  HEAD 

the  method  of  treating  common  incised  wounds;  but  proceed  im- 
mediately to  those  which,  though  the  mischief  be  originally  con- 
fined to  the  mere  scalp,  yet  are  frequently  very  terrible  to  behold, 
are  often  attended  with  alarming  symptoms,  and  sometimes  with 
danger.  These  are  what  are  called  lacerated  wounds,  and  those 
made  by  puncture.  The  former  may  be  reduced  to  two  kinds, 
viz.  those  in  which  the  scalp,  though  torn,  or  unequally  divided, 
still  keeps  its  natural  situations,  and  is  not  stripped  or  separated 
from  the  cranium  to  any  considerable  distance  beyond  the  breadth 
of  the  wound;  and  those,  in  which  it  is  considerably  detached  from 
the  parts  it  ought  to  cover. 

The  first  of  these,  if  simple,  and  not  combined  with  the  symp- 
toms or  appearances  of  any  other  mischief,  do  not  require  any  par- 
ticular or  different  treatment  from  what  the  same  kind  of  wounds 
require  on  all  other  parts;  but  the  latter  (those  in  which  the  scalp 
is  separated  and  detached  from  the  parts  it  ought  to  cover)  are  not 
only,  by  the  different  methods  in  which  they  may  be  treated,  fre- 
quently capable  of  being  cured  with  a  considerable  deal  more  or 
less  ease  and  expedition,  but  prove  also  sometimes  matter  of  great 
consequence  to  the  health  and  well-being  of  the  patient.  Both 
writers  and  practitioners  differ  much  in  their  advice  and  conduct 
on  this  subject.  With  some  it  is  a  practice  immediately  to  remove 
such  portion  of  the  scalp  as  is  fairly  and  perfectly  detached 
from  the  parts  underneath;  with  others,  to  attempt  its  preserva- 
tion. 

Each  of  these  opinions  can  be  considered,  in  a  general  sense 
only,  not  as  applicable  to  every  individual  case  without  distinction; 
and  taken  in  such  general  consideration,  they  cannot  be  both  right. 
It  may  therefore  be  worth  while  to  inquire,  what  reasons  each 
party  has  to  give  for  its  opinion  and  conduct. 

They  who  advise  the  removal  affirm,  that  when  a  large  por- 
tion of  the  scalp  has  been  perfectly  and  totally  separated  from 
the  parts  it  ought  to  cover,  and  that  for  some  considerable  space, 
it  will  not  again  coalesce  or  unite  with  such  parts;  and  therefore 
that  an  attempt  to  procure  such  union,  by  replacing  the  separated 
piece,  will  only  protract  the  time  of  cure,  by  furnishing  a  lodg- 
ment for  matter  and  sloughs,  which  matter  and  sloughs  must  pre- 
vent the  thing  intended.     That  in  case  of  large  wounds,  or  of 


PROM  EXTERNAL  VIOLENCE.  33 

those  produced  by  great  force,  as  we  cannot  by  any  means  be 
absolutely  certain  that  no  mischief  is  done  to  the  parts  under  the 
cranium,  the  replacing  the  lacerated  scalp  may  not  only  prevent 
our  immediate  inquiry  into  the  nature  of  such  mischief,  but  may 
conceal  and  hide  (at  least  for  a  time)  such  future  appearances  as 
might  furnish  indications  to  direct  a  surgeon's  conduct. 

They  who  advise  the  preservation  of  the  separated  scalp,^  do 
it  upon  a  supposition,  that  it  will  in  general  unite  again;  that  if 
it  do,  the  patient  may  thereby  be  spared  a  great  deal  of  pain,  save 
much  time,  and  sustain  much  less  deformity;  that  with  regard  to 
the  immediate  inquiry  into  the  state  of  the  cranium,  it  may  be 
made  before  the  scalp  is  replaced;  that  if  there  be  no  present 
symptoms  which  indicate  injury  done  to  the  parts  underneath,  it 
would  be  absurd  to  act  merely  upon  the  presumption  that  there 
may  be  some  in  future;  that  it  will  be  more  proper  and  vindicable 
to  do  what  is  right  at  first,  or  according  to  the  present  circum- 
stance, and  to  attend  to  what  may  happen  or  occur  hereafter, 
when  such  occurrences  have  happened;  and  that  the  formation  of 
matter  and  sloughs,  under  the  detached  and  replaced  portion,  will 
not,  in  general,  under  proper  management,  prevent  its  re-union. 

It  is  to  be  presumed,  that  every  practitioner  wishes  to  cure  his 
patients  as  soon  as  he  can,  by  the  least  painful  means,  and  in 
such  manner  as  shall  be  productive  of  the  least  possible  deformity 
or  defect;  taking  care  at  the  same  time,  not  to  be  inattentive  to 
any  evil  which  may  arise,  nor  to  omit  or  neglect  doing  whatever 
maybe  necessary  during  such  cure. 

Upon  this  principle,  I  make  no  scruple  of  declaring  it  as  my 
opinion,  that  the  preservation  of  the  scalp  ought  always  to  be  at- 
tempted, unless  it  be  so  torn  as  to  be  absolutely  spoiled,  or  there 
are  manifest  present  symptoms  of  other  mischief.  This  kind  of 
wound  is  sometimes  very  terrible  to  look  upon,  and  they  who  have 
not  been  accustomed  to  see  it,  may  be  inclined  to  think  there  is 
no  remedy  but  excision:  but  I  have  so  often  made  the  experiment 
of  endeavouring  to  preserve  the  torn  piece,  and  have  so  oft§n 
succeeded,  that  I  would  recommend  it  as  a  thing  always  to  be  at-  ^ 

*  I  presume  I  need  not  observe,  that  when  I  say  separated,  I  mean  only 
with  regard  to  the  inferior  surface  of  such  piece,  and  that  it  is  still  contiguous 
with  some  part  of  the  skin. 

VOL.  I.  E 


34  INJURIES  OF  THE  HEAD 

tempted,  even  though  a  part  of  the  cranium  shoukl  be  perfectly 
bare,  unless  the  two  circumstances  already  mentioned  render  it 
improper  or  impracticable.  The  removal  of  it  necessarily  pro- 
duces a  larger  sore,  which  must  require  a  good  deal  of  time  to 
heal,  and  must  leave  a  considerable  deformity:  the  preservation  of 
it  prevents  both. 

Therefore,  when  such  case  occurs,  let  the  surgeon  be  particu- 
larly careful  to  examine,  whether  there  be  any  appearances,  or 
symptoms,  of  any  other  kind  of  mischief  beside  what  the  scalp 
has  sustained;  and  if  there  be  neither,  let  him  make  the  torn  piece 
clean  from  all  dirt,  or  foreign  bodies,  and  restore  it  quickly,  and 
as  perfectly  as  he  can,  to  its  natural  situation*'' 

^  The  distance  from  the  place  where  the  accident  happens,  and  other 
causes,  frequently  prevent  the  surgeon  from  examining  the  wound,  until  a 
considerable  time  has  elapsed,  when,  without  any  application  having  been 
made  to  it,  the  surface  of  the  torn  scalp,  and  the  parts  which  adhere  to  the 
cranium,  are  become  dry,  and  are  apparently  not  in  a  state  to  lieal  by  tlie 
first  intention ;  or  some  dressings  may  have  been  applied,  wliicli,  by  the 
nature  of  them,  and  by  keeping  the  parts  separate,  add  to  the  indisposition 
to  unite.     In  either  of  these  cases,  notwithstanding  many  hours  may  have  in- 
tervened, this  excellent  idea  of  saving  the  scalp  need  not  be  abandoned  ;  on 
the  contrary,  after  the  wound  has  been  thoroughly  washed  and  cleansed,  the 
surfaces  of  it  should  be  lightly  scai-ified  with  the  point  of  a  lancet ;  when, 
being  thus  refreshed,  and  yielding  a  small  effusion  of  blood,  the  immediate 
union  between  them  will  probably  take  place,  provided  they  are  brought 
into  contact,  and  retained  as  Mr.  Pott  directs. — To  explain  my  meaning,  I 
will  select  the  following  instance  :  A  gentleman,  about  twenty  years  old, 
thrown  from  his  horse,  and  entangled  in  the  stirrup,  received  a  kick  on  the 
forehead.     As  he  was  at  a  great  distance  from  London,  I  did  not  see  him  till 
forty  hours  after  the  accident :  he  had  been,  and  still  continued,  in  a  state  of 
insensibility  :  the  horse's  shoe  had  struck  him  on  the  edge  of  the  orbit,  and 
had  torn  the  eye-brow  and  nearly  one  half  of  the  covering  of  the  forehead, 
which  was  raised,  and  formed  a  flap.     The  wound,  which  was  very  large, 
had  been  filled  soon  after  the  accident,  with  lint :  it  immediately  occurreii 
to  me,  that,  if  it  were  suffered  to  heal  in  this  situation,  the  consequent  de- 
formity must  be  deplorable.     I  therefore  removed  the  dressings,  and  found 
the  OS  frontis  denuded  in  two  places :  there  was  no  fracture,  except  of  a 
small  portion  of  bone,  which  had  been  broken  off  from  the  edge  of  the  orbit, 
and  his  symptoms  were  those  of  general  concussion.    I  conceived  it  would 
be  right  to  endeavour  to  procure  an  union  of  the  separated  parts,  though 
from  the  length  of  time  since  they  had  been  divided,  and  from  the  dressings, 
which  had  left  the  fibres  dry  and   constringed,  they  appeared  very  ill  dis- 
posed  to  unite.    However,  after  having  got  rid  of  the  remainder  of  the  lint. 


PROM  EXTERNAL  VIOLENCE.  35 

The  manner  in  which  it  is  to  be  there  maintained,  must  a  good 
deal  depend  upon  the  particular  circumstances  of  each  individual 
case,  and  therefore  must  be  left  to  the  surgeon,  who  will  make 
use  of  plaster,  bandage,  and  suture,  together  or  separately,  as 

and  made  it  perfectly  clean  with  warm  water,  I  scarified  the  whole  internal 
surface  of  tiie  detached  scalp,  and  the  parts  of  the  muscle  which  still  adhered 
to  the  bone,  which  his  absence  of  perception  enabled  me  to  perform  freely. 
I  then  brought  them  into  contact,  and  retained  them  in  that  situation  by  the 
dry  suture.  I  had  the  satisfaction  to  find  them  unite  by  the  first  intention, 
making  a  simple  line  nearly  down  the  middle  of  the  forehead.  By  proper 
treatment  he  soon  regained  his  senses ;  and  a  small  exfoliation  from  the  edge 
of  the  orbit,  at  the  bottom  of  the  wound,  was  the  only  circumstance  which 
for  some  time  retarded  the  perfect  cure. 

I  will  mention  another  case  In  which  very  different  treatment,  but  equally 
wrong,  had  taken  place  before  I  saw  the  patient : — 

A  man  sitting  on  the  shafts  of  a  loaded  waggon  fell  down  in  a  fit :  as  he  lay 
On  his  face,  the  wheel  passed  over  the  right  side  of  the  head,  tore  off  the 
whole  of  the  scalp  from  the  parietal  and  temporal  bones,  and  from  part  of  the 
frontal  bone.  The  integuments  also  which  covered  the  under  part  of  the 
orbit  and  cheek  were  much  torn  and  bruised  :  in  short,  a  more  completely 
mangled  and  shocking  object  can  scarcely  be  imagined. 

The  whole  of  this  large  wound  I  found  covered  with  a  soft  greas)'  poultice. 
On  taking  it  off,  though  the  wound  had  been  in  some  measure  washed  and 
cleansed,  the  remaining  mud  mixed  with  blood  presented  the  appearance  of 
a  dirty  quagmire,  in  which  the  wounded  portions  were  loose  and  floating, 
but  still  retained  some  connexion  with  the  neighbouring  parts.  The  poultice 
had  been  applied  all  night,  and  part  of  the  day.  Ii  is  evident  at  first  sight 
that  the  consequence  of  the  continuance  of  such  application  must  be  the 
sloughing  and  destruction  of  all  these  parts  ;  and  if  life  were  preserved,  the 
poor  sufferer  must  remain  a  miserable  object.  I  therefore  ordered  it  to  be 
well  cleansed  in  every  part  with  warm  water,  the  doing  of  which  completely 
was  not  an  easy  task.  When  this  was  thoroughly  accomplished,  I  scarified 
freely  every  part  of  the  wound  over  the  whole  surface  of  the  parts  which 
still  adhered  to  the  bones  as  well  as  the  inside  of  the  torn  portions  of  scalp, 
which,  though  so  ragged,  so  torn  to  shreds  and  tatters  that  I  thought  it  im- 
possible that  they  should  all  unite,  I  would  not  suffer  to  be  I'emoved,  but 
gave  them  all  a  chance,  thinking  that  those  parts  which  should  die  from  want 
of  circulation,  might  easily  be  taken  away  at  some  future  opportunity.  I 
then  brought  all  the  p.arts  as  nearly  as  possible  into  their  natural  situation, 
and  retained  them  by  means  of  ligatures,  strips  of  sticking  plaster,  and 
bandages  liglitly  applied. 

Some  blood  was  taken  from  the  arm,  which,  with  open  bowels  and  a  low 
diet,  prevented  considerable  inflammation  from  coming  on.  From  day  to 
day  such  strips  of  sticking  plaster  as  were  loose  were  removed,  and  others 


36  INJURIES  OP  THE  HEAD 

he  shall  find  them  most  convenient,  and  best  fitted  to  the  pur*^- 
pose. 

I  am  aware  that  the  very  mention  of  a  suture  in  a  wound  of 
the  scalp,  particularly  a  lacerated  one,  will  startle  some  of  my 
readers,  who  have  been  taught  that  it  is  always  wrong  in  both; 
I  know  that  this  is  the  general  doctrine,  but  I  know  also,  that  al- 
though it  be  sometimes  true,  yet,  if  it  be  implicitly  adhered  to,  it 
will  prevent  a  practitioner  now  and  then  from  receiving  very  use- 
ful assistance.  A  stitch,  made  with  a  slip-knot,  will  sometimes 
hold  the  divided  parts  in  such  situation,  as  will  greatly  expedite  a 
cure:  in  many  cases  a  very  short  time  will  answer  the  end,  and 
the  thread  may  be  removed  as  soon  as  ever  the  purpose  is  accom- 
plished, or  the  suture  becomes  either  improper  or  useless. 

In  some  cases  this  will  be  all  that  is  required;  the  loosened 
scalp  will  unite  with  the  parts  from  which  it  was  torn  and  sepa- 
rated, and  there  will  be  no  other  sore,  than  what  arises  from  the 
impracticability  of  bringing  the  lips  of  the  wound  into  smooth  and 
immediate  contact,  the  scar  of  which  sore  must  be  small  in  pro- 
portion. 

On  the  other  hand,  it  sometimes  happens  that  such  perfect  re- 
union is  not  to  be  obtained;  in  which  case,  matter  will  be  formed 
and  collected  in  those  places  where  the  parts  do  not  coalesce:  but 
this  does  not  necessarily  make  any  difference,  either  in  the  gene- 
ral intention,  or  in  the  event:  this  matter  may  easily  be  discharged, 
by  one  or  two  small  openings  made  with  a  lancet;  the  head  will 

applied.  In  the  progress  of  a  few  days  I  was  agreeably  surprised  to  see  that 
in  general  an  union  liad  taken  place,  except  on  the  sides  of  some  of  the 
smaller  portions  of  the  detached  scalp,  and  the  extremities  of  others  which 
remained  black  and  lifeless,  and  which  of  course  were  taken  away;  and 
particularly  there  was  a  small  portion  under  the  eye,  which,  being  dead  for 
want  of  a  nourisliing  vessel,  sloughed  and  came  away,  and  threatened  a  con- 
siderable disfigurement.  The  loss  however  was  greatly  remedied  by  bring- 
ing the  neighbouring  parts  as  nearly  together  as  possible.  In  no  great 
length  of  time  the  whole  wound  was  healed,  when  all  those  who  had  witness- 
ed the  accident,  and  observed  its  progi-ess  toward  amendment,  as  well  as  my- 
self, were  astonished  at  the  little  scar  or  deformity  left  from  so  extensive  and 
complicated  a  wound. 

I  may  add,  that  the  man,  before  the  accident,  had  been  reckoned  hand- 
some, and  the  front  view  of  his  face  afterward  still  retained  its  comely  ap- 
pearance.       E. 


PROM  EXTERNAL  VIOLENCE.  37 

&till  preserve  its  natural  covering;  and  the  cure  will  be  very  little 
retarded  by  a  few  small  abscesses. 

I  must  desire  not  to  be  misunderstood:  I  do  not  mean  to  say, 
that  it  must  be  always  and  invariably  right,  to  return  the  loosened 
scalp,  and  to  endeavour  to  procure  its  immediate  re-union,  or  that 
such  attempt  will  always  succeed;  I  only  mean  to  signify,  that  it 
is  my  opinion,  (and  that  founded  on  experience,)  that  the  mere  se- 
paraiion  or  detachment  of  the  scalp,  to  however  large  an  extent,  is 
not  a  good  and  sufficient  reason  for  cutting  off  any  part  of  it  in 
cases  where  no  other  mischief  seems  to  have  been  done,  in  which 
the  cranium  is  uninjured,  and  the  parts  within  it  unhurt;  and,  that 
the  attempt  to  procure  a  re-union  with  the  parts  from  which  it  was 
separated,  though  it  will  sometimes  fail,  yet  will  most  frequently 
succeed;  and  is  always  worth  making;  as  such  experiment,  pro- 
perly made,  can  never  be  attended  with  any  real  inconveniences. 

In  some  cases,  the  whole  separated  piece  will  ^i(as  I  have  said 
before)  unite  perfectly,  and  give  little  or  no  trouble,  especially  in 
young  and  healthy  persons;  in  some,  the  union  will  take  place  in 
some  parts,  and  not  in  others;  and  consequently  matter  will  be 
formed,  and  require  to  be  discharged,  perhaps  at  several  different 
points;  and  in  some  particular  cases,  circumstances,  and  habits, 
there  will  be  no  union  at  all:  the  torn  cellular  membrane,  or  the 
naked  aponeurosis,  will  inflame  and  become  sloughy,  a  considera- 
ble quantity  of  matter  will  be  collected,  and  perhaps  the  cranium 
will  be  denuded:  but  even  in  this  state  of  things,  which  does  not 
very  often  happen  where  proper  care  has  been  taken,  and  is  almost 
the  worst  which  can  happen  in  the  case  of  mere  simple  laceration 
and  detachment,  I  say,  even  in  this,  if  the  surgeon  will  not  be  too 
soon,  nor  too  much  alarmed,  nor  in  a  hurrry  to  cut,  he  will  often 
find  the  cure  much  more  feasible  than  he  may  at  first  imagine:  let 
him  take  care  to  keep  the  inflammation  under  by  proper  means; 
let  him  have  patience  till  the  matter  is  fairly  and  fully  formed,  and 
the  sloughs  perfectly  separated;  and  when  this  is  accomplished, 
let  him  make  a  proper  number  of  dependent  openings  for  the  dis- 
charge of  them;  and  let  him  by  bandage,  and  other  proper  ma- 
nagement, keep  the  parts  in  constant  contact  with  each  other,  and 
he  will  often  find,  that,  although  he  was  foiled  in  his  first  intention, 
of  procuring  immediate  union,  yet  he  will  frequently  succeed  in 


$8 


INJURIES  OF  THE  HEAD 


this  his  second;  he  will  still  save  the  scalp,  shorten  the  cure,  and 
prevent  the  great  deformity  arising  (particularly  to  women)  not 
only  from  the  scar,  but  from  the  total  loss  of  hair. 

I  have  said, that  this  union  may  often  be  procured,  even  though 
the  cranium  should  have  been  perfectly  denuded  by  the  accident; 
and  it  is  true,  not  only  though  it  should  have  been  stripped  of  its 
pericranium  at  first,  but  even  if  that  pericranium  should  have  be- 
come sloughy  and  cast  off,  as  I  have  often  seen. 

Exfoliation  from  a  cranium  laid  bare  by  external  violence,  and 
to  which  no  other  injury  has  been  done  than  merely  stripping  it  of 
its  covering,  is  a  circumstance  which  would  not  so  often  happen, 
if  it  were  not  taken  for  granted  that  it  must  be,  and  the  bone  treat-' 
ed  according  to  such  expectation:  the  soft  open  texture  of  the  bones 
of  children  and  young  people  will  frequently  furnish  an  incarna- 
tion, which  will  cover  their  surface,  and  render  exfoliation  quite 
unnecessary;  and  even  in  those  of  mature  age,  and  in  whom  the 
bones  are  still  harder,  exfoliation  is  full  as  often  the  effect  of  art, 
as  the  intention  of  nature,  and  produced  by  a  method  of  dressing, 
calculated  to  accomplish  such  end,  under  a  supposition  of  its  being 
necessary.  Sometimes  indeed  it  happens  that  a  small  scale  will 
necessarily  separate,  and  the  sore  cannot  be  perfectly  healed  till 
such  separation  has  been  made:  but  this  kind  of  exfoliation  will 
be  very  small  and  thin,  in  proportion  to  that  produced  by  art, 
which  is,  that  produced  by  dressing  the  surface  of  the  bare  bone 
with  spirituous  tinctures,  &c.;  and  when  a  wound  on  the  head, 
with  a  sound  uninjured  bone,  denuded  by  accident,  shews  a  dis- 
position to  heal  without  exfoliation,  it  never  can  be  right  to  coun- 
teract nature,  and  oblige  her  to  do  that  she  is  not  inclined  to,  and 
which  she  would  otherwise  accomplish  better. 

If  the  scalp  be  detached  by  such  means,  or  with  such  force  of 
instrument,  that  the  scull  or  parts  within  it  have  suffered,  then 
tlie  immediate  union  of  the  skin  becomes  impracticable,  and  it 
would  be  highly  injudicious  to  attempt  it:  our  attention  then  must 
be  paid  to  the  greater  evil;  it  then  becomes  another  kind  of  case, 
and  all  that  need  be  said  of  it  in  this  place  is,  that  although  such 
mischief  do  generally  require  the  removal  of  some  part,  yet  even  in 
this  situation,  no  more  of  it  should  be  cut  off  than  what  will  be  ne- 
cessary for  the  detection  and  proper  treatment  of  such  mischief. 


FROM  EXTERNAX.  VIOLENCE.  39 

In  short,  whether  considered  as  skin,  or  as  the  seat  of  the  hair,  it 
ought  never  to  be  removed  wantonly,  or  without  absolute  neces- 
sity. 

Small  wounds,  that  is,  such  as  are  made  by  instruments  or  bo- 
dies which  pierce  or  puncture  rather  than  cut,  are  in  general  more 
apt  to  become  inflamed,  and  to  give  trouble,  than  those  which  are 
larger;  and  in  this  part  particularly  are  sometimes  attended  with 
so  high  inflammation  and  with  suqh  symptoms,  as  alarm  both  pa- 
tient and  surgeon. 

The  parts  capable  of  being  hurt  by  such  kind  of  wound,  are 
the  skin,  the  tela  cellulosa,  the  expanded  tendons  of  the  muscles 
of  the  scalp,  and  the  pericranium. 

If  the  wound  be  no  deeper  than  the  cellular  membrane,  and  has 
not  reached  the  aponeurosis  or  pericranium,  the  inflammation  and 
tumour  affect  the  whole  head  and  face,  the  skin  of  which  wears  a 
yellowish  cast,  and  is  sometimes  thick  set  with  small  blisters,  con- 
taining the  same  coloured  serum;  it  receives  the  impression  of  the 
fingers,  and  becomes  pale  for  a  moment,  but  returns  immediately 
to  its  inflamed  colour;  it  is  not  very  painful  to  the  touch,  and  the 
eye-lids  and  ears  are  always  comprehended  in  the  tumefaction, 
the  former  of  which  are  sometimes  so  distended,  as  to  be  closed; 
a  feverish  heat  and  thirst  generally  accompany  it;  the  patient  is 
restless,  has  a  quick  pulse,  and  most  commonly  a  nausea,  and  in- 
clination to  vomit. 

This  accident  generally  happens  to  persons  of  bilious  habit,  and 
is  indeed  an  inflammation  of  the  erysipelatous  kind;  it  is  somewhat 
alarming  to  look  at,  but  it  is  not  often  attended  with  danger.  The 
wound  does  indeed  neither  look  well,  nor  yield  a  kindly  discharge, 
while  the  fever  continues,  but  still  it  has  nothing  threatening  in 
its  appearance,  none  of  that  look  which  bespeaks  internal  mis- 
chief; the  scalp  continues  to  adhere  firmly  to  the  scull,  and  the 
patient  does  not  complain  of  that  tensive  pain,  nor  is  afflicted 
with  that  fatiguing  restlessness  which  generally  attends  mischief 
underneath  the  cranium. 

Phlebotomy,  lenient  purges,  and  the  use  of  the  common  febri- 
fuge medicines,  particularly  those  of  the  neutral  kind,  generally 
remove  it  in  a  short  time.  When  the  inflammation  is  gone  off", 
it  leaves  on  the  skin  a  yellowish  tint,  and  a  dry  scurf;  which  con- 


40  INJURIES  OF  THE  HEAD 

tinue  until  perspiration  carries  them  away,  and  upon  the  disap- 
pearance of  the  disease,  the  wound  immediately  recovers  a  healthy 
aspect,  and  soon  heals  without  any  further  trouble. 

Wounds  and  contusions  of  the  head,  which  affect  the  brain  and 
its  membranes,  are  also  subject  to  an  erysipelatous  kind  of  swell- 
ing and  inflammation;  but  it  is  very  different,  both  in  its  charac- 
ter and  consequences,  from  the  preceding. 

In  this  (which  is  one  of  the  effects  of  inflammation  of  the  me- 
ninges) the  febrile  symptoms  are  much  higher,  the  pulse  harder 
and  more  frequent,  the  anxiety  and  restlessness  extremely  fatiguing, 
the  pain  in  the  head  intense;  and  as  this  kind  of  appearance  is, 
in  these  circumstances,  most  frequently  the  immediate  precursor 
of  matter  forming  between  the  scull  and  dura  mater,  it  is  general- 
ly attended  with  irregular  shiverings,  which  are  not  followed  by  a 
critical  sweat,  nor  afford  any  relief  to  the  patient.  To  which  it 
may  be  added,  that  in  the  former  case  the  erysipelas  generally 
appears  within  the  first  three  or  four  days;  whereas  in  the  latter, 
it  seldom  comes  on  till  several  days  after  the  accident,  when  the 
symptomatic  fever  is  got  to  some  height.  In  the  simple  erysipe- 
las, although  the  wound  be  crude  and  undigested,  yet  it  has  no 
other  mark  of  mischief;  the  pericranium  adheres  firmly  to  the 
scull,  and,  upon  the  cessation  of  the  fever,  all  appearances  become 
immediately  favourable.  In  that  which  accompanies  injury  done 
to  the  parts  underneath,  the  wound  not  only  has  a  spongy,  glassy, 
unhealthy  aspect,  but  the  pericranium  in  its  neighbourhood  sepa- 
rates spontaneously  from  the  bone,  and  quits  all  cohesion  with  it. 
In  short,  one  is  an  accident,  proceeding  from  a  bilious  habit,  and 
not  indicating  any  mischief  beyond  itself;  the  other  is  a  symptom, 
or  a  part  of  a  disease,  which  is  occasioned  by  injury  done  to  the 
membranes  of  the  brain;  one  portends  little  or  no  ill  to  the  pa- 
tient, and  almost  always  ends  well;  the  other  implies  great  haz- 
ard, and  most  commonly  ends  fatally.  It  fs  therefore  hardly  ne- 
cessary to  say,  that  it  behoves  every  practitioner  to  be  careful  in 
distinguishing  them  from  each  other. 

If  the  wound  be  a  small  one,  and  has  passed  through  the  tela 
cellulosa,  to  the  aponeurosis,  and  pericranium,  it  is  sometimes  at- 
tended with  very  disagreeable,  and  even  very  alarming  symptoms, 


FROM  EXTERNAL  VIOLENCE.  41 

Ijut  which  arise  from  a  different  cause,  and  are  very  distinguish- 
able from  what  has  been  yet  mentioned. 

In  this  the  inflamed  scalp  does  not  rise  into  that  degree  of  tume- 
faction, as  in  the  erysipelas;  neither  does  it  pit,  or  retain  the  im- 
pression of  the  fingers  of  an  examiner:  it  is  of  a  deep  red  colour, 
unmixed  with  the  yellow  tint  of  the  erysipelas:  it  appears  tense, 
and  is  extremely  painful  to  the  touch.  As  it  is  not  an  affection  of 
the  tela  cellulosa,  and  as  the  ears  and  the  eye-lids  are  not  covered 
by  the  parts  in  which  the  wound  is  inflicted,  they  are  seldom,  if 
ever,  comprehended  in  the  tumour,  though  they  may  partake  of 
the  general  inflammation  of  the  skin:  it  is  generally  attended  with 
acute  pain  in  the  head,  and  such  a  degree, of  fever  as  prevents 
sleep,  and  sometimes  brings  on  a  delirium." 

A  patient  in  these  circumstances  will  admit  more  free  evacua- 
tions by  phlebotomy,  than  one  labouring  under  an  erysipelas:  the 
use  of  warm  fomentation  is  required  in  both,  in  order  to  keep  the 
skin  clean  and  perspirable;  but  an  emollient  cataplasm,  which  is 
generally  forbid  in  the  former,  may  in  this  latter  case  be  used  to 
great  advantage. 

When  the  symptoms  are  not  very  pressing,  nor  the  habit  very 
inflammable,  this  method  will  prove  sufficient:  but  it  sometimes 
happens,  that  the  scalp  is  so  tense,  the  pain  so  great,  and  the 
symptomatic  fever  so  high,  that  by  waiting  for  the  slow  effect  of 
such  means,  the  patient  runs  a  risque  from  the  continuance  of 
the  fever;  or  else  the  injured  aponeurosis  and  pericranium  be- 
coming sloughy,  produce  an  abscess,  and  render  the  case  both 
tedious  and  troublesome.  A  division  of  the  wounded  part  by  a 
simple  incision  down  to  the  bone,  about  half  an  inch  or  an  inch 

'In  the  last  lecture  which  Mr.  Pott  gave  on  this  subject,  he  candidly  ob- 
served, that  he  found  he  had  drawn  the  line  of  distinction  between  those 
wounds  by  whicli  the  tela  cellulosa  alone  is  hurt,  and  those  which  penetrate 
through  and  puncture  the  aponeurosis  and  pericranium,  too  decidedly,  and 
said  he  was  convinced,  that  the  different  symptoms  which  he  had  supposed 
to  follow  the  wound  of  this  or  that  part,  often  arose  from  the  constitution 
and  habit  of  the  person  woiuided,  rather  than  from  the  nature  of  the  accident, 
and  that  the  consequences  could  not  always  be  deducible  from  the  particu- 
lar part  which  had  received  the  injury ;  for  that,  since  be  had  written  on  the 
subject,  he  had  remarked  the  s^me  symptoms  indiscriminately  arising  from 
either  kind  of  wound.        E. 

VOL.  I.  P 


4S  INJURIES  Of  THE  HEAD 

in  length,  will  most  commonly  remove  all  the  bad  symptoms,  anc? 
if  it  be  done  in  time,  will  render  every  thing  else  unnecessary. 

The  injuries  to  which  the  scalp  is  liable  from  contusion,  or  the 
appearances  produced  in  it  by  such  general  cause,  may  for  method- 
sake  be  divided  into  two  classes,  viz.  those  in  which  the  mischief 
is  confined  merely  to  the  scalp,  and  those  in  which  other  parts  are 
interested. 

The  former,  which  only  comes  under  our  present  consideration, 
is  not  indeed  of  importance,  considered  abstractedly.  The  tu- 
mour attending  it  is  either  very  easily  dissipated,  or  the  extrava- 
sated  blood  causing  it,  is  easily  got  rid  of  by  a  small  opening.  I 
should  not  therefore  have  thought  it  of  such  consequence,  as  to  be  , 
worth  mentioning  in  this  place,  bad  it  not  been  for  an  accidental 
circumstance,  which  sometimes  attends  it,  and  renders  it  liable  to 
be  very  much  mistaken. 

When  the  scalp  receives  a  very  smart  blow,  it  often  happens 
that  a  quantity  of  extravasated  blood  immediately  forms  a  tumour, 
easily  distinguishable  from  all  others,  and  generally  very  easily 
cured.  But  it  also  sometimes  happens,  that  this  kind  of  tumour 
produces  to  the  fingers  of  an  unadvised  or  inattentive  examiner,  a 
sensation,  so  like  to  that  of  a  fracture,  with  depression  of  the  cra- 
nium, as  may  be  easily  mistaken.  Now,  if  upon  such  supposi- 
tion, a  surgeon  immediately  removes  the  tumid  scalp,  he  may 
give  his  patient  a  great  deal  of  unnecessary  pain,  and  for  that 
reason  run  some  risque  of  his  own  character. 

The  touch  is,  in  this  case,  so  liable  to  deception,  that  recourse 
should  always  be  had  to  other  circumstances  and  symptoms,  be- 
fore an  opinion  be  given. 

If  a  person,  with  such  tumour  occasioned  by  a  blow,  and  at- 
tended with  such  appearances  and  feel,  have  any  complaint,  which 
seems  to  be  the  effect  of  pressure  made  on  the  brain  and  nerves, 
or  of  any  mischief  done  to  the  parts  within  the  cranium,  the  divi- 
sion or  removal  of  the  scalp,  in  order  to  inquire  into  the  state  of 
the  scull,  is  right  and  necessary;  but  if  there  be  no  such  general 
symptoms,  and  the  patient  be  in  every  respect  perfectly  well,  the 
mere  feel  of  something  like  a  fracture  will  not  authorise  or  vindi- 
cate such  operation,  since  it  will  often  be  found,  that  such  sensa- 
tion is  a  deception,  and  that  when  the  extravasated  fluid  is 


PROM  EXTERNAL  VIOLENCE.  43 

removed,  or  dissipated,  the  cranium  is  perfectly  sound  and  un- 
injured. 

The  second  kind  of  tumour  attending  the  contused  scalp,  viz. 
ihat  which  arises  from  injury  done  to  the  cranium,  and  parts  with- 
in, does  so  absolutely  proceed  from,  and  depend  upon  such  injury, 
as  not  to  fall  under  our  consideration  iii  this  place  at  all,  but  will 
be  considered  at  large  when  we  come  to  speak  of  the  mischiefs 
done  to  the  scull  and  brain  by  collision,  or  contusion. 

From  what  has  been  said  it  appears,  that  the  scalp,  taken  in  a 
general  sense,  is,  vi'hen  wounded  or  bruised,  liable  to  be  affected 
with  four  kinds  of  tumour,  each  of  which  has  a  distinct  cause,  and 
requires,  or  permits,  a  different  method  of  treatment. 

The  first  does  not  imply  any  injury  done  to  the  parts  within 
the  scull,  requires  no  operation,  and  almost  always  is  cured  by 
general  remedies. 

The  second,  or  tliat  which  is  caused  by  the  spontaneous  sepa- 
ration of  the  pericranium  from  the  scull,  in  consequence  of  inter- 
nal mischief,  is  not  at  first  attended  with  very  pressing  symptoms; 
but  whoever  has  observed  their  progress,  and  attended  to  their 
event,  must  know  what  fatal  and  frequently  irresistible  evil  it  is 
the  forerunner  of,  nothing  less  than  the  inflammation  and  putre- 
faction of  the  membranes  of  the  brain,  and  the  formation  of  mat- 
ter between  them  and  the  scull;  and  that  it  is  a  case  which,  of  all 
others,  will  least  admit  delay. 

The  third,  though  it  sometimes  gives  way  to  free  evacuation, 
and  lenient  external  applications,  yet  is  sometimes  also  attended 
with  symptoms  which  are  too  pressing  to  wait  the  effect  of  such 
remedies,  and  is  capable  of  being  immediately  relieved  by  a  divi- 
sion of  the  inflamed  and  irritated  parts;  whereas  the  same  incision, 
made  into  the  first  kind  of  tumefaction,  would  most  probably  ex- 
asperate the  disease,  and  heighten  the  symptoms. 

The  fourth,  consisting  of  extravasated  blood,  seldom  requires 
any  chirurgic  operation;  time,  and  the  use  of  the  common  discu- 
tient  applications,d  almost  always  dissipate  Jt;  and  it  only  becomes 
of  consequence  by  the  possibility  of  its  being  misunderstood  and 
mistreated. 

^  Among  which  I  know  of  none  equal  to  a  solution  of  crude  fal  almon.  in 
vinegar  and  water,  or  spt.  vin. 


44  *  INJURIES  OF  THE  HEAD 


SECT.  II. 

EFFECTS  OF  CONTUSION  ON  THE  DURA  MATER,  AND  PARTS  WITHIN 
THE  SCULL. 

In  order  fo  understand  rightly,  and  to  have  a  clear  idea  of  this 
kind  of  injury,  it  is  necessary  to  recollect,  that  the  vessels  of  the 
pericranium,  those  of  the  diploe,  or  medullary  substance  between 
the  two  tables  of  some  parts  of  the  cranium,  and  those  of  the 
dura  mater  within  it,  do  all  constantly  and  freely  comrtaunicate 
with  each  other;  and  that  this  communication  is  carried  on  by 
means  of  innumerable  foramina,  found  in  all  parts  of  both  sur- 
faces of  the  scull,  as  well  as  at  the  sutures;  that  upon  the  freedom 
of  this  communication  depends  the  healthy  and  sound  state  of  all 
the  parts  concerned  in  it;  and  that  from  the  interruption  or  de- 
struction of  this  proceed  most  of  the  symptoms  attending  violent 
contusions  of  the  head,  extravasations  of  fluid  between  the  cranium 
and  dura  mater,  inflammations  of  the  said  membrane,  and  simple 
undepressed  fracture  of  the  scull. 

The  pericranium  is  so  firmly  attached  to  the  outer  surface  of 
the  scull,  as  not  to  be  separable  from  it  without  considerable  vio- 
lence; and  when  such  violent  separation  is  made  in  a  living  sub- 
ject (especially  if  young)  the  cranium  is  always  seen  to  bleed 
freely,  from  an  infinite  number  of  small  foramina.  The  dura 
mater,  which  is  a  firm  strong  membrane,  is  almost  as  intimately 
attached  to  the  inside  of  the  scull,  as  the  pericranium  is  to  the  out- 
side, and  by  the  same  means,  viz.  by  vessels;  and  by  these  means 
a  constant  circulation  and  communication  are  preserved  and  main- 
tained between  the  two  membranes  and  the  bones  dividing  them. 
This,  all  the  appfjarances  which  attend  the  scalping  a  living  per- 
son, or  the  separation  of  the  scull  from  the  dura  mater  of  a  dead 
one,  (especially  if  such  person  died  apoplectic,  or  was  hanged,) 
prove  beyond  all  doubt :  in  the  former,  the  blood  will  (as  I  have 
already  observed)  be  seen  issuing  from  every  point  of  the  surface 
of  the  cranium;  in  the  latter,  not  only  a  considerable  degree  of 
force  will  be  found  necessary  to  detach  the  sawed  bone  from  the 


FROM  EXTERNAL  VIOLENCE.  45 

subjacent  membrane,  but  when  it  is  removed,  a  great  number  of 
bloody  points  wili  be  seen  all  over  the  surface  of  the  laUer;  which 
points,  if  wiped  clean,  do  immediately  become  bloody  again,  being 
only  the  extremities  of  broken  vessels.  These  vessels  are  largest 
at,  and  about  the  sutures,  at  which  places  the  adhesion  is  the 
strongest,  and  the  haemorrhage  upon  separation  the  greatest. 

It  has  been  thought  by  many,  that  the  dura  mater  was  attached 
to  the  scull  only  at  the  sutures;  that  in  all  other  parts  it  was  loose 
and  unconnected  with  it;  and  that  it  constantly  enjoyed  or  per- 
formed an  oscillatory  kind  of  motion,  and  was  alternately  elevated 
and  depressed.  This  idea  and  opinion  were  borrowed  from  the 
appearance  which  the  dura  mater  makes  in  a  living  subject  after 
a  portion  of  the  scull  has  been  removed:  but  although  it  has  been 
inculcated  by  writers  of  great  eminence,  yet  it  has  no  foundation 
in  truth  or  nature,  and  has  misled  many  practitioners  in  their 
opinions,  not  only  of  the  structure  and  disposition  of  this  mem- 
brane, but  in  their  idea  of  its  diseases. 

The  dura  mater  performs  on  the  internal  surface  of  the  bones  of 
the  cranium,  the  office  of  periosteum,  in  the  same  manner  as  the 
pericranium  does  on  the  external;  (at  least  they  have  no  other:) 
to  this  it  is  so  firmly  and  so  generally  attached,  as  to  be  incapable 
of  any,  even  the  smallest  degree  of  motion.  The  alternate  eleva- 
tion and  subsidence  of  it,  which  are  observable  when  any  portion 
of  it  is  laid  bare,  are  owing  to  a  very  different  cause  from  any 
power  in  itself;  neither  is,  nor  can  ever  be  performed,  until  a 
piece  of  the  cranium  has  been  forcibly  taken  away;  and  conse- 
quently cannot  possibly  be  natural,  or  necessary. 

By  blows,  falls,  and  other  shocks,  some  of  the  larger  of  tliose 
vessels  which  carry  on  this  communication  between  the  dura  mater 
and  the  scull  are  broken,  and  a  quantity  of  blood  is  shed  upon  the 
surface  of  that  membrane.  This  is  one  species  of  bloody  extrava- 
sation, and  indeed  the  only  one  which  can  be  formed  between  the 
scull  and  dura  mater.  If  the  broken  vessels  be  few,  and  the  quan- 
tity of  blood  which  is  shed  be  small,  the  symptoms  are  generally 
slight,  and  by  proper  treatment  disappear.  When  they  are  large, 
or  numerous,  or  the  quantity  of  extravasated  fluid  considerable, 
the  symptoms  are  generally  urgent  in  proportion;  but  whether 
they  be  slight  or  considerable,  whether  immediately  alarming  or 


46  INJURIES  OF  THE  HEAI> 

not,  they  are  always,  and  uniformly,  such  as  indicate  pressure 
made  on  the  brain  and  nerves,  viz.  stupidity,  drowsiness,  diminu- 
tion or  loss  of  sense,  speech,  and  voluntary  motion. 

This  every  practitioner  knows  to  be  one  frequent  consequence 
of  blows  on  the  head.  But  it  also  often  happens,  from  the  same 
kind  of  violence,  that  some  of  the  small  vessels,  which  carry  on 
the  circulation  between  the  pericranium,  scull,  and  dura  mater, 
are  so  damaged,  as  not  to  be  able  properly  to  execute  that  office, 
although  there  be  none  so  broken  as  to  cause  an  actual  effusion  of 
blood. 

Smart  and  severe  strokes  on  the  middle  part  of  the  bones,  at  a 
distance  from  the  sutures,  are  most  frequently  followed  by  this 
kind  of  mischief:  the  coats  of  the  small  vessels,  which  sustain 
the  injury,  inflame  and  become  sloughy,  and,  in  consequence  of 
such  alteration  in  them,  the  pericranium  separates  from  the  out- 
side of  that  part  of  the  bone  which  received  the  blow,  and  the 
dura  mater  from  the  inside;  the  latter  of  which  membranes,  soon 
after  such  inflammation,  becomes  sloughy  also,  and  furnishes 
matter;  which  matter  being  collected  between  the  said  membrane 
and  the  cranium,  and  having  no  natural  outlet  whereby  to  escape, 
or  be  discharged,  brings  on  a  train  of  very  terrible  symptoms,  and 
is  a  very  frequent  cause  of  destruction.^  The  effect  of  this  kind 
of  violence  is  frequently  confined  to  the  vessels  connecting  the 
dura  mater  to  the  cranium,  in  which  case  the  matter  is  external  to 
the  said  membrane;  but  it  sometimes  happens,  that,  by  the  force 
either  of  the  stroke  or  of  the  concussion,  the  vessels  which  pass 
between  and  connect  the  two  meninges  are  injured  in  the  same 
manner;  in  which  case,  the  matter  formed  in  consequence  of  such 
violence  is  found  on  the  surface  of  the  brain,  or  between  the  pia 
and  dura  mater,  as  well  as  on  the  surface  of  the  latter;  or  perhaps 
in  all  these  three  situations  at  the  same  time. 

«  Comment  le  perlcrane  a-l-il  pu  ainsi  se  detacher  de  I'os  dans  le  circon- 

ference  du  coup  ?  ne  seroit  ce  point  par  I'ebranlement  ou  le  tremoussement 

de  toutes   les  parties   integrantes  du  crane  ?  Si  c'est  en  consequence  d'un 

tremoussement  pareil   que  nombre  de  filets  qui  attachent  le  perici'ane  au 

crane  se  sont  detaches,  par  la  meme  raison,  plusieurs  des  filets  qui  attachent 

la  dure  mere  au  crane  out  du  se  romprv"  aussi :  d'oii  s'en  suivit  un  erysipele, 

qu'occaslon  suppuration,  ou  plutot  pourriture. 

Le  DsAy. 


E*ROM  EXTERNAL  VIOLENCE.  41 

The  difference  of  this  kind  of  disease,  from  either  an  extravasa- 
tion of  blood,  or  a  commotion  of  the  medullary  parts  of  the  brain, 
is  great  and  obvious.  All  the  complaints  produced  by  extravasa- 
tion are  (as  I  have  already  said)  such  as  proceed  from  pressure 
made  on  the  brain  and  nerves,  and  obstruction  to  the  circulation 
of  the  blood  through  the  former;  stupidity,  loss  of  sense,  and 
voluntary  motion,  laborious  and  obstructed  pulse  and  respiration, 
&c.  and  (which  is  of  importance  to  remark)  if  the  effusion  be  at 
all  considerable,  these  symptoms  appear  immediately,  or  very  soon 
after  the  accident. 

The  symptoms  attending  an  inflamed  or  sloughy  state  of  the 
membranes,  in  consequence  of  external  violence,^  are  very  dif- 
ferent; they  are  all  of  the  febrile  kind,  and  never,  at  first,  imply 
any  unnatural  pressure;  such  are,  pain  in  the  head,  restlessness, 
want  of  sleep,  frequent  and  hard  pulse,  hot  and  dry  skin,  flushed 
countenance,  inflamed  eyes,  nausea,  vomiting,  rigor;  and,  toward 
the  end,  convulsion  and  delirium.  And  none  of  these  appear  at 
first,  that  is,  immediately  after  the  accident ;  seldom'  mitil  some 
days  are  past.^ 

One  set  or  class  of  symptoms  are  produced  by  an  estravasated 
fluid,  making  such  pressure  on  the  brain  and  origin  of  the  nerves, 
as  to  impair  or  abolish  voluntary  motion  and  the  senses;  the  other 

^  The  diiference  between  these  two  effects  of  external  violence,  was  very 
well  understood  by  Berengarius  Carpensis,  a  most  excellent  writer  on  this 
subject,  who  says,  "  Interdum  eliam  acontusione  non  rumpitur  ahqua  vena, 
"  sed  rumpnntur  ligamenta  ilia  durse  matris  ;  a  qulbus  resudat  aliquid  :  hisce 
"  vero  nisi  succuratur,  accidunt  sjeva  accidentia,  et  mors." 

Paulus  ^T,gineta  has  also  very  particularly  distins^uished  between  that  de- 
gree of  contusion,  wliich  affects  only  the  outer  table  of  the  scull,  and  that 
which  injures  the  dura  mater.  "Porro  contusionis  hujus  duse  existunt  dif- 
"  ferentire  :  vel  enim  calva  per  totam  ipsius  crassitiem  contunditur,  ut  fre- 
"quenter  etiam  cerebri  membrana  abscessu  occupetur;  vel,  &c." 

g  "  Nulla  autem  haruni  contusionum  aspectu  dignosci  potest ;  qualis  nenipe, 
"  quantave  sit.     Non  protlnus  ab  ictu  malum  se  videndima  praibet." 

IltPPOCRATES. 

"Sed  accidentia  quje  sequuntur  ad  prrcdiclam  conlusionera,  inter  commis- 
"suras,  non  sunt  per  contusionem  tanlum  ;  sed  sunt  pi'v pnlrefaclioiiem pan- 
"niadi  Ixsi,  et  cum  venit  ad  certam  quantitatem  determinatam  incipit  febris, 
"  et  alia  accidentia :  et  tandem  seqnitur  mors,  nisi  cito  succuratur." 

Jacob cs  Behexgauius  Cabpetssis. 


48  INJURIES  OF  THE  UEAli 

is  caused  by  the  inflamed  or  putrid  state  of  the  membranes  cover- 
ing the  brain,  and  seldom  affects  the  organs  of  sense,  until  the  lat- 
ter end  of  the  disease,  that  is,  until  a  considerable  quantity  of  mat- 
ter is  formed,  which  matter  must  press  like  any  other  fluid. 

I  am  very  sensible  that  it  is  a  generally-received  opinion,  that 
blood  shed  from  its  vessels,  ainl  remaining  confined  in  one  place, 
will  become  pus;  and  that  the  matter  found  on  the  surface  of  the 
dura  mater,  towards  the  end  of  these  cases,  was  originally  extra- 
vasated  blood.  I  apprehend  both  these  positions  to  be  false.  That 
pure  blood  shed  from  its  vessels,  by  means  of  external  violence, 
and  kept  from  the  air,  will  not  turn  to,  or  become  matter,  is 
(I  think)  proved  incontestibly  by  every  day's  experience,  in  many 
instances,  in  aneurisms  by  puncture,  in  retained  menses  by  im- 
perforate vaginae,  and  in  all  ecchymoses.  True  pus  cannot  be 
made  from  blood  merely,  as  may  be  known  from  the  manner  in 
which  all  abscesses  are  formed,  and  from  every  circumstance  at- 
tending suppuration;  and  that  the  matter  found  on  the  surface  of 
the  dura  mater,  after  great  contusions  of  the  head,  never  was 
mere  blood,  I  am  as  certain  as  observation  and  experience  can 
make  me. 

Some  of  the  French  writers  have  indeed  divided  the  symptoms 
of  what  they  call  a  contusion  of  the  head,  into  two  kinds,  and 
have  named  them  primitive  or  original  symptoms,  and  secondary 
or  consequential  ones:  among  the  former,  they  rank  immediate 
loss  of  sense,  haemorrhage,  involuntary  discharge  of  urine  and 
faeces,  great  propensity  to  sleep,  &c.;  among  the  latter  they  reckon 
fever,  delirium,  rigor,  convulsion,  &c.  One  kind  they  impute  to 
the  mere  extravasation  of  blood,  the  other  to  its  putrefaction. 

This  account,  though  ingenious  and  specious,  is  not  founded  on 
fact.  It  is  true,  that  the  two  kinds  of  symptoms  are  very  distinct 
from  each  other,  as  well  in  their  nature,  as  in  their  time  and  man- 
ner of  access,  and  so  far  the  remark  is  true;  but  from  all  the  ob- 
servation and  examination  which  I  have  been  able  to  make,  both 
on  the  living  and  on  the  dead,  they  appear  to  me  to  proceed  from 
very  different  causes.  That  both  these  kinds  of  symptoms  do  now 
and  then  concur  in  the  same  patient,  is  beyond  all  doubt;  and 
that  the  case  is  thereby  rendered  complex,  and  more  difficult  to 
jje  judged  of;  but  this  does  not  constantly  happen;  and  even  when 


FROM  EXTERNAL  VIOLENCE.  49 

it  does,  I  cannot  help  thinking,  that  there  are  generally  such  dis- 
tinguishing characteristic  marks  of  each,  as  may  prove  the  truth 
of  what  I  have  asserted. 

In  order  to  explain  my  meaning  as  clearly  as  I  can,  I  will  con- 
sider the  inflammatory  effect  of  contusion  by  itself,  and  indepen- 
dent of  every  other  complaint  or  injury,  which  may  accidentally 
be  joined  with  it. 

If  there  be  neither  fissure  nor  fracture  of  the  scull,  nor  extra- 
vasation, nor  commotion  underneath  it,  and  the  scalp  be  neither 
considerably  bruised  nor  wounded,  the  mischief  is  seldom  disco- 
vered or  attended  to  for  some  few  day£  The  first  attack  is  ge- 
nerally by  pain  in  the  part  which  received  the  blow.  This  pain, 
though  beginning  in  that  point,  is  soon  extended  all  over  the 
head,  and  is  attended  with  a  languor,  or  dejection  of  strength  and 
spirits,  which  are  soon  followed  by  a  nausea,  and  inclination  to 
vomit,  a  vertigo  or  giddiness,  a  quick  and  hard  pulse,  and  an  in- 
capacity of  sleeping,  at  least  quietly.  A  day  or  two  after  this 
attack,  if  no  means  preventative  of  inflammation  are  used,  the 
part  stricken  generally  swells,  and  becomes  puffy  and  tender,  but 
not  painful;  neither  does  the  tumour  rise  to  any  considerable 
height,  or  spread  to  any  great  extent.  If  this  tumid  part  of  the 
scalp  be  now  divided,  the  pericranium  will  be  found  of  a  darkish 
hue,  and  either  quite  detached,  or  very  easy  separable  from  the 
scull,  between  which  and  it  will  be  found  a  small  quantity  of  a 
dark-coloured  ichor. 

If  the  disorder  has  made  such  progress,  that  the  pericranium  is 
quite  separated  and  detached  from  the  scull,  the  latter  wall  even 
now  be  found  to  be  somewhat  altered  in  colour  from  a  sound 
healthy  bone.  Of  this  alteration  it  not  very  easy  to  convey  an 
idea  by  words,  but  it  is  a  very  visible  one,  and  what  some  very 
able  writers  have  noticed."* 

''  Among  these  Fallopius  particularly:  "  Inspiciatis  diligenter  os  detectum ; 
"  quod  OS,  quando  est  in  natura  sua,  est  coloris  subrubri,  non  caiididi  pror- 
"  sus,  nee  nibri  prorsiis,  sed  est  veluti  color  mistus  ex  albo  declinans  ad  rubi- 
"  cundura,  vit  si  multo  lacte,  aut  alio  colore  candido,  poneres  pavum  sanguinis 
"  vel  allerius  rei  rubra:.  Sed  si  videritis  inseqiialitatem  coloris  in  ipso  osse  de- 
"  tecto,  ita  ud  adsiiit  veluti  puncta  coleris  albi,  et  aridi  ossis,  quae  aridae  par- 
"  ticulze  alicniando  niajores  sunt,  aliquando  minores,  &c.  sciatis  quod  os  sit 
■"  contusum."  Failopibs. 

VOL.  I.  & 


50  INJURIES  OF  THE  HEAD 

From  this  time  the  symptoms  generally  advance  more  hastily 
an^cl  more  apparently;  the  fever  increases,  the  skin  becomes  hotter, 
the  pulse  quicker  and  harder,  the  sleep  more  disturbed,  the  anxiety 
and  restlessness  more  fatiguing,  and  to  these  are  generally  added 
irregular  rigors,  which  are  not  followed  by  any  critical  sweat,  and 
which,  instead  of  relieving  the  patient,  add  considerably  to  his 
sufferings.  If  the  scalp  has  not  been  divided  or  removed,  until 
the  symptoms  are  thus  far  advanced,  the  alteration  of  the  colour 
of  the  bone  will  be  found  to  be  more  remarkable;  it  will  be  found 
to  be  whiter  and  more  dry  than  a  healthy  one,  or,  as  Fallopius 
has  very  justly  observed,  it  will  be  found  to  be  more  like  a  dead 
bone:  the  sanies,  or  fluid,  between  it  and  the  pericranium  will 
also,  in  this  state,  be  found  to  be  more  in  quantity,  and  the  said 
membrane  will  have  a  more  livid  diseased  aspect. 

In  this  state  of  matters,  if  the  dura  mater  be  denuded,  it  will  be 
found  to  be  detached  from  the  inside  of  the  cranium,  to  have  lost 
its  bright  silver  hue,  and  to  be,  as  it  were,  smeared  ov^r  with  a 
kind  of  mucus,  or  with  matter,  but  not  with  blood.  Every  hour 
after  this  period,  all  the  symptoms  are  exasperated,  and  advance 
with  hasty  strides:  the  head-ach  and  thirst  become  more  intense, 
the  strength  decreases,  the  rigors  are  more  frequent,  and  at  last 
convulsive  motions,  attended  in  some  with  delirium,  in  others  with 
paralysis,  or  comatose  stupidity,  finish  the  tragedy.' 

'The  whole  process  of  this  very  terrible  disease  is  very  accurately  related 
and  very  justly  accounted  for,  by  Theodoric.  "  Si  vero  ob  ictus  veiiementiam, 
"  dura  nialer  ah  esse  fuerit  separwla  :  vel  aliqiio  modo  Isesa  (sano  &,  ill8eso 
"  existente  cranio)  sic  cognosces :  cum  dolor  capitis,  li.  lenta  febris,  singulis 
"  diebus  augmentantur,  oculorum  anguli,  ac  si  spasmari  vellent,  distorquen- 
"  tur ;  gense  rubent ;  (quod  signum  pravum  est  in  qualibet  capitis  Ijesione;) 
"  pannus  balneatus  superpositus,  citius  desiccatur ;  cutis  etiam  arida  et  sicca ; 
"  et  si  vulnus  fuerit,  et,  os  disco-opertum,  color  ossis  velocius  alteratur;  et 
"  propter  negligentiam  curse,  Kgro  superveniuTit  dolores,  et  febres,  spasmus, 
"  syncope,  et  permistio  rationis." 

Theohor  de  viiln.  capic. 

"  Qua  vero  super  cerebri  membranam  sit,  ulraqua  ratione  difficilis  est  .- 
"  ns'.m  leesis  membi-anis  apparet ;  ideo  enim  febris  cum  horrore  accediuit,  fli- 
"  ciei  rubor,  et  calor,  longe  mnjor  qiiam  pro  febris  modo  ;  somnique  tumul- 
"  tuosi ;  oculi  subf^ngues,  et  giainiosi  et  rubentes." 

Archigesks  fie  sangvine  svbtercurrente. 

Petrus  e  Largelata,  having  very  accurately  related  the  s)  mptoms  attending 
the  formation  of  matter  under  the  ci-aiiium  when  fiacturcd,  says:  "  Si  autem 


FROM   EXTERNAL  VJOLENOE.  51 

If  the  scalp  has  not  been  divided  or  removed  till  this  point  of 
time,  and  it  be  done  now,  a  very  offensive  discoloured  kind  of 
fluid  will  be  found  lying  on  the  bare  cranium,  whose  appearance 
will  be  still  more  unlike  to  the  healthy  natural  one:  if  the  bone  be 
now  perforated,  matter  will  be  found  between  it  and  the  dura  ma- 
ter, generally  in  considerable  quantity,  but  different  in  different 
cases  and  circumstances.  Sometimes  it  will  be  in  great  abun- 
dance, and  diffused  over  a  very  large  part  of  the  membrane;  and 
sometimes  the  quantity  will  be  less,  and  consequently  the  space 
which  it  occupies  smaller.  Sometimes  it  lies  only  on  the  exte- 
rior surface  of  the  dura  mater;  and  sometimes  it  is  between  it 
and  the  pia  mater,  or  also  even  on  the  surface  of  the  brain,  or 
within  the  substance  of  it. 

The  primary  and  original  cause  of  all  this,  is  the  stroke  upon 
the  skull:  by  this  the  vessels  which  should  carry  on  the  circula- 
tion between  the  scalp,  pericranium,  scull,  and  meninges,  are  in- 
jured, and  no  means  being  used  to  prevent  the  impending  mis- 
chief, or  such  as  have  been  made  use  of  proving  ineffectual,  the 
necessary  and  mutual  communication  between  all  these  parts 
ceases:  the  pericranium  is  detached  from  the  scull,  by  means  of  a 
sanies  discharged  from  the  ruptured  vessels;  the  bone  being  de- 
prived of  its  due  nourishment  and  circulation  loses  its  healthy  ap- 
pearance; the  dura  mater  (its  attaching  vessels  being  destroyed, 
or  rendered  unfit  for  their  office)  separates  from  the  inside  of  the 
cranium,  inflames,  and  suppurates. 

Whoever  will  attend  to  the  appearances  which  the  parts  con- 
cerned make  in  every  stage  of  the  disease,  to  the  nature  of  the 
symptoms,  the  time  of  their  access,  their  progress,  and  most  fre- 
quent event,  will  find  them  all  easily  and  fairly  deducible  from 
the  one  cause,  which  has  just  been  assigned,  viz.  the  contusion. 
As  the  inflammation  and  separation  of  the  dura  mater  is  not  an 
imimdiate  consequence  of  the  violence,  so  neither  are  the  symp- 
toms immediate,  seldom  until  some  days  have  passed;  the  fever 

"  fractura  sit  parva  et  penetrans,  tunc  fiiint  ilia  signa  post  aliquod  tempus; 
"  eo  quod  tunc  humiditates  qtiae  sunt  sub  cranio  putrefiunt;  et  tunc  fiunt  ilia 
"  accidentia  :"  And  then  very  justly  adds,  "  Secundo  notes  quod  omnia  ilia 
"  accidentia  possunt  advenire  ex  percussione  capitis,  cranio  non  fracto." 

Pet.  £  Labg£i.ata. 


53  INJURIES  OF  THE  HEAD 

at  first  is  slight,  but  increases  gradually;  as  the  membrane  be- 
comes more  and  more  diseased,  all  the  febrile  symptoms  are 
heightened;  the  formation  of  matter  occasions  rigors,  frequent 
and  irregular,  until  such  a  quantity  is  collected,  as  brings  on  de- 
lirium, spasm,  and  death. 

Hitherto  I  have  considered  this  disease,  as  unaccompanied  by 
any  other,  not  even  by  any  external  mark  of  injury,  except  per- 
haps a  trifling  bruise  of  the  scalp;  let  us  now  suppose  the  scalp 
to  be  wounded  at  the  time  of  the  accident,  by  whatever  gave  the 
contusion;  or  let  us  suppose,  that  the  immediate  symptoms  having 
been  alarming,  a  part  of  the  scalp  had  been  removed  in  order  to 
examine  the  scull;  in  short,  let  the  injury  be  considered  as  joined 
with  a  wounded  scalp. 

In  this  case,  the  wound  will  for  some  little  time  have  the  same 
appearance  as  a  mere  simple  wound  of  this  part,  unattended  with 
other  mischief,  would  have;  it  will,  like  that,  at  first  discharge  a  thin 
sanies,  or  gleet,  and  then  begin  to  suppurate;  it  will  digest,  begin 
to  incarn,  and  look  perfectly  well;  but,  after  a  few  days,  all  these 
favourable  appearances  will  vanish;  the  sore  will  lose  its  florid 
complexion  and  granulated  surface;  will  become  pale,  glassy,  and 
flabby;  instead  of  good  matter,  it  will  discharge  only  a  thin  dis- 
coloured sanies;  the  lint  with  which  it  is  dressed,  instead  of  com- 
ing off  easily,  (as  in  a  kindly  suppurating  sore,)  will  stick  to  all 
parts  of  it;  and  the  pericranium,  instead  of  adhering  firmly  to  the 
bone,  will  separate  from  it,  all  round,  to  some  distance  from  the 
edges.'' 

This  alteration  in  the  face  and  circumstances  of  the  sore  is 
produced  merely  by  the  diseased  state  of  the  parts  underneath 

•«  "  Ubicunque  autem  ex  vulnere  intereundum  sit,  neque  possit  homo 
"  sanitatem  recipere,  neque  servavi,  ex  his  intelligere  convenit  moriturum  ; 
"  et  quod  futurum  est  prognosticare.  Hyeme  plerumque,  ante  diem  quar- 
*'  tum,  sestate  post  septimum,  accedit  febris  ;  quae  quum  supervenit,  vuhius 
"redditnon  sui  coloris,  etsaniem  modicam  effundit,  quodque  ex  ipso  inflam- 
"  matum  est  emoritur,  glutinosum  efRcitur,  et  camera  sale  conditam  reprse- 
"sentat." 

HippocHATES  de  vuln.  capit. 

"  Ulcus  neque  alitur  neque  pus  maturat,  et  sordidum  sit." 

AnCHIGESES. 


FROM  EXTERNAL  VIOLENCE.  53 

the  scull;  which  is  a  circumstance  of  great  importance,  in 
support  of  the  doctrine  advanced;  and  is  demonstrably  proved, 
by  observing  that  this  diseased  aspect  of  the  sore,  and  this 
spontaneous  separation  of  the  pericranium,  are  always  con- 
fined to  that  part  which  covers  the  altered  or  injured  portion 
of  the  dura  mater,  and  do  not  at  all  affect  the  rest  of  the  scalp; 
nay,  if  it  has  by  accident  been  wounded  in  any  other  part, 
or  a  portion  has  been  removed  from  any  part  where  no  injury  has 
been  done  to  the  dura  mater,  no  such  separation  will  happen;  the 
detachment  above  will  always  correspond  to  that  below,  and  be 
found  no  where  else. 

The  first  appearance  of  alteration  in  the  wound  immediately 
succeeds  the  febrile  attack;  and  as  the  febrile  symptoms  increase, 
the  sore  becomes  worse  and  worse,  that  is,  degenerates  more  and 
more  from  a  healthy,  kindly  aspect. 

Through  the  whole  time,  from  the  first  attack  of  the  fever,  to 
the  last  and  fatal  period,  an  attentive  observer  will  remark  the 
gradual  alteration  of  the  colour  of  the  bone,  if  it  be  bare.  At  first 
it  will  be  found  to  be  whiter,  and  more  dry,  than  the  natural  one; 
and  as  the  symptoms  increase,^  and  either  matter  is  collected,  or 
the  dura  mater  becomes  sloughy,  the  bone  inclines  more  and  more 
to  a  kind  of  purulent  hue,  or  whitish  yellow;  and  it  may  also  be 
worth  while  in  this  place  to  remark,  that  if  the  blow  was  on  or 
very  near  to  a  suture,  and  the  subject  young,  the  said  suture  will 
often  separate  in  such  manner  as  to  let  through  it  a  loose,  painful 

1  "Tandem  subpalHdum  vel  album  se  ostendit;  ubi  autem  jam  purulen- 
"  turn  est,  aut.pustulcc  in  lingua  nascuntur,  laborans  mente  non  constante  con- 
"  sumitur." 

Hippocrates  de  indn.  capitis. 

"  Quando  sanies  est  infra  cranium,  ipso  non  fracto,  cranium  est  male  colo- 
"ratum:  aeger  sentit  gravidinem  in  ea  parte  qua  est  sanies. — Est  os  sanum, 
"  id  est  illud  cui  adhseret  dura  mater  coloris  albi,  misti  rubedine. — Et  quo 
<*separatio  est  major,  eo  major  ossisquantitas  est  mutata  in  colore. — Ultra 
"  yero  colorem,  cognoscitur  etiam  eo  quod  siccius  sit  sano. — Et  ultra  colorem 
"  et  siccitatem,  quando  incipit  ista  separatio,  incipiunt  aliqua  sseva  acci- 
"  dentia  ;  et  febris,  mentis  alienatio,  stupor,  vigilae,  &c.  Quia  incipit  supra 
"■  pamuculum  aggregari  materia,  qux  incipit  corrumpi." 

Jacobus  Berksgarius  Cabfeksis. 


54  INJURIES  OF  THE  HEAD 

ill-natured  fungus;  at  which  time  also  it  is  no  uncommon  thing  for 
the  patient's  head  and  face  to  be  attacked  with  an  erysipelas.™ 

I  have  saidj  that  in  those  cases  in  which  the  scalp  is  very  little 
injured  by  the  bruise,  and  in  which  there  is  no  wound,  nor  any 
immediately  alarming  symptoms  or  appearances,  that  the  patient 
feels  little  or  no  inconvenience,  and  seldom  makes  any  complaint, 
until  some  (ew  days  are  past.  That  at  the  end  of  this  uncertain 
time,  he  is  generally  attacked  by  the  symptoms  already  recited; 
that  these  are  not  pressing  at  first,  but  that  they  soon  increase  to 
such  a  degree,  as  to  baffle  all  our  art:  from  whence  it  will  appear, 
that  when  this  is  the  case,  the  patient  frequently  suffers  from  what 
seems  at  first  to  indicate  his  safety,  and  prevents  such  attempts 
being  made,  and  such  care  from  being  taken,  as  might  prove  pre- 
ventative of  mischief. 

But  if  the  integuments  are  so  injured  as  to  excite  or  claim  our 
early  regard,  very  useful  information  may  from  thence  be  collect- 
ed; for  whether  the  scalp  be  considerably  bruised,  or  whether  it 
be  found  necessary  to  divide  it  for  the  discharge  of  extravasated 
blood,  or  on  account  of  worse  appearances,  or  more  urgent  symp- 
toms, the  state  of  the  pericranium  may  be  thereby  sooner  and  more 
certainly  known:  if  in  the  place  of  such  bruise,  the  pericranium 
be  found  spontaneously  detached  from  the  scull,  having  a  quantity 
of  discoloured  sanies  between  them  under  the  tumid  part,  in  the 
manner  I  have  already  mentioned,  it  may  be  regarded  as  a  pretty 
certain  indication,  either  that  the  dura  mater  is  beginning  to  sepa- 
rate in  the  same  manner,  or  that  if  some  preventative  means  be 
not  immediately  used,  it  will  soon  suffer;  that  is,  it  will  inflame, 
separate  from  the  scull,  and  give  room  for  a  collection  of  matter 
between  them.  And  with  regard  to  the  wound  itself,  whether  it 
was  made  at  the  time  of  the  accident,  or  afterward  artificially,  it 
is  the  same  thing;  if  the  alteration  of  its  appearance  be  as  I  have 
related,  if  the  edges  of  it  spontaneously  quit  their  adhesion  to  the 
bone,  and  the  febrile  symptoms  are  at  the  same  time  making  their 
attack,  these  circumstances  will  serve  to  convey  the  same  informa- 
tion, and  to  prove  the  same  thing."* 

"*  "  Suturas  tempore  curationis  disjungi  grave  est." 

Archigises  de  SiGirrs. 
"  Si  dans  ane  playe  contuse,  otj  le  crane  est  decouvert,  on  trouve  a  la  cir- 


FROM  EXTERNAL  VIOLENCE.  55 

This  particular  effect  of  contusion  is  frequently  found  to  attend 
«n  fissures  and  undepressed  fractures  of  tiie  cranium,  as  well  as 
on  extravasations  of  fluid,  in  cases  where  the  bone  is  entire;  and, 
on  the  other  hand,  all  these  do  often  happen  without  the  concur- 
rence of  this  individual  mischief.  All  this  is  matter  of  accident; 
but  let  the  other  circumstances  be  what  they  may,  the  spontaneous 
separation  of  Ihe  altered  pericranium,  in  consequence  of  a  severe 
blow,  is  almost  always  followed  by  a  suppuration  between  the 
cranium  and  dura  mater;  a  circumstance  extremely  well  worth 
attending  'to  in  fissures  and  undepressed  fractures  of  the  scull,  be- 
cause, it  is  from  this  circumstance  principally  that  the  bad  symp- 
toms and  the  hazard  in  such  cases  arise. 

It  is  no  very  uncommon  thing  for  a  smart  blow  on  the  head  to 
produce  some  immediate  bad  symptoms,  which  after  a  short  space 
of  time  diappear,  and  leave  the  patient  perfectly  well.  A  slight 
pain  in  the  head,  a  little  acceleration  of  pulse,  a  vertigo  and  sick-^ 
ness,  sometimes  immedicitely  follow  such  accident,  but  do  not  con- 
tinue many  hours,  especially  if  any  evacuation  has  been  used. 
These  are  not  improbably  owing  to  a  slight  commotion  of  the 
brain,  which,  having  suffered  no  material  injury  thereby,  soon 
cease.  But  if,  after  an  interval  of  some  time,  the  same  symptoms 
are  renewed;  if  the  patient,  having  been  well,  becomes  again 
feverish  and  restless,  and  that  without  any  new  cause;  if  he  com- 
plains being  languid  and  uneasy,  sleeps  disturbedly,  loses  his  ap- 
petite, has  a  hot  skin,  a  hard  quick  pulse,  and  a  flushed,  heated 
countenance;  and  neither  irregularity  of  diet,  nor  accidental  cold, 
has  been  productive  of  these;  mischief  is  most  certainly  impend- 
ing, and  that  most  probably  under  the  scull. 

If  the  symptoms  of  pressure,  such  as  stupidity,  loss  of  sense, 
voluntary  moiion,  &c.  appear  some  few  days  after  the  head  has 
suffered  injury  from  external  mischief,  they  do  most  probably  imply 
aneffusionof  a  fluid  somewhere:  this  effusion  may  be  in  the  sub- 
stance of  the  brain,  in  its  ventricles,  between  its  membranes,  or  on 

conference  de  la  playe,  que  le  pericrane  tienne  pen  a  crane,  ou  en  soit  de- 
tache,  c'est  une  preuye  certaine  que  le  crane  a  soiifFert,  quoiqu'il  ne  soit 
fracture  ;  et  s'il  a  soufFert,  on  peut  etre  assure  que  la  dure  mere  a  souffert 
aussi. 

Le  Drak. 


S6  INJURIES  OF  THE  HKAD 

the  surface  of  the  dura  mater;  and  which  of  these  is  the  real 
situation  of  such  extravasation,  is  a  matter  of  great  uncertainty, 
none  of  them  being  attended  with  any  peculiar  mark  or  sign  that 
can  be  depended  upon  as  pointing  it  out  precisely;  but  the  inflam- 
mation of  the  dura  mater,  and  the  formation  of  matter  between  it 
and  the  scull,  in  consequence  of  contusion,  is  generally  indicated 
and  preceded  by  one  which  I  have  hardly  ever  known  to  fail,  I 
mean  a  puffy,  circumscribed,  indolent  tumor  of  the  scalp,  and  a 
spontaneous  separation  of  the  pericranium  from  the  scull  under 
such  tumor." 

These  appearances,  therefore,  following  a  smart  blow  on  the 
head,  and  attended  with  languor,  pain,  restlessness,  watching, 
quick  pulse,  head-ach,  and  slight  irregular  shiverings,  do  almost 
infallibly  indicate  an  inflamed  dura  mater,  and  pus  either  forming 
or  formed  between  it  and  the  cranium. p 

By  detachment  of  the  pericranium,  I  do  not  mean  every  sepa- 
ration of  it  from  the  bone  which  it  should  cover.  It  may  be,  and 
often  is  cut,  torn,  or  scraped  off,  without  any  such  consequence; 
but  these  separations  are  violent,  whereas  that  which  I  mean  is 
spontaneous,  and  is  produced  by  the  destruction  of  those  vessels  by 
which  it  was  connected  with  the  scull,  and  by  which  the  commu- 
nication between  it  and  the  internal  parts  was  carried  on;  and 

°  Lorsqu'on  trouve  le  perlcrane  detaclie,  il  n'y  a  point  a  hesiter  a.  faire  le 
tvepan.  Je  S9ais  que  dans  ua  cas  pareii  on  n'auroit  rien  trouve  d'epanchd 
sous  le  crane,  mais  cependant  I'operation  faite  de  bonne  heure  auroit  et^ 
I'unique  mo}  en  de  sauver  le  malade  s'il  etoit  possible,  &c. 

Si  done  plusieurs  experiences  nous  apprennent  que  la  dure  mere  devient 
malade  en  consequeiice  de  la  contusion  de  I'os,  et  que  sa  maladie  degenere 
en  pournturCjCe  qui  a  jusqii'icl  empore  plusieurs  malades  malgre  de  recours 
usites,  il  faut  absolument  trepanner  de  bonne  heure. 

Le  Dkak. 

P  Si  statira  ab  initio  febris  primo  aut  secundo  appareat  die,  ilia  procul  dubio 
causam  agnoscat  perturbalionem  humorum,  ac  animi,  quum  vulnus  incute- 
retur  ;  cessante  causa  procatarctica  ;  ac  ubi  se  collegerit  seger,  desinat  ilia 
febricula.  Si  vero  primis  diebus,  nihil  febrile,  nee  ullum  symptoma  sentiat 
jeger,  seque  in  nuUo  discrimine  existimat,  hunc  si  subito,  die  scilicet  septimo, 
vel  quarto  decimo  (nihil  licet  in  victu,  rebusve  externis  peccaverit  seger)  ac 
prster  expectationem  febris  invadat,  significat  latens  aliquod,  in  cranio^  ce- 
rebro,  aut  corpore  vulnerati. 

Pet.  Paaw.  in  Hippoubat. 


FROM  EXTERNAL  VIOLENCE.  6t 

therefore  it  is  to  be  observed,  that  it  is  not  the  mere  removal  of 
that  membrane  which  causes  the  bad  symptoms,  but  it  is  the  in- 
flammation of  the  dura  mater,  of  which  inflammation  this  sponta- 
neous secession  of  the  pericranium  is  an  almost  certain  indica- 
tion. 

A  false  notion  prevailed  for  many  years,  that  the  dura  mater  was 
not  in  general  connected  with  the  internal  surface  of  the  scull,  ex- 
cept at  the  sutures;  and  that  in  all  other  parts  of  it,  such  a  vacancy 
was  left  as  gave  free  room  for  what  they  called  its  pulsatory  mo- 
tion.i    This  opinion,  which  was  embraced  by  many,  even  of  the 

9  If  we  consider  how  clearly  and  plainly  many  of  the  best  ancient  writers 
describe  the  intimate  connexion  between  the  scull  and  dura  mater,  and  how 
perfectly  well  acquainted  many  of  them  were  with  its  morbid  separation,  we 
shall  wonder  how  it  came  to  be  again  foi'got ;  but  that  it  was,  is  most  certain. 
In  Hippocrates,  Paulus  JEgineta,  Rhazes,  and  others,  are  many  passages 
which  prove  their  knowledge  of  the  natural  structure  and  adhesion  of  this 
membrane  ;  and  that  some  of  the  most  eminent  writei's  and  practitioners  had 
forgot,  or  did  not  attend  to  it,  the  following  quotations,  selected  from  many 
more,  may  evince. 

"  Dura  mater  calvariae  connectitur  futurarum  ope  ut  pensile  et  erectum 
"teneat  cerebrum;  turn  etiam  ut  per  suturas  egressa  pericranium  procreat: 
"  spatium  vero  inter  suturas  recte  natura  liberum  reliquit  ut  vacuum  quod- 
"  dam  esset  inter  duram  matrem  et  calvariam  ;  has  nimirum  ob  causas ;  prime 
"  ne  quicquam  cerebri  systolse  et  diastolje  obstaret ;  secundo  ne  venae,  et  ar- 
"teriae  per  externam  duras  matris  partem  sparsae  levi  ahquo  ictu  in  cranio 
"facto  rumperentur;  postremo  ut  ruptis  in  dura  matre  venis,  sanguis  non 
"  inter  duram  et  piam  matrem,  sed  inter  duram  et  cranium  effunderetur,  et 
"  cranio  perforato  facilius  extraheretur.    Et  hie  est  ordinarius  naturae  ordo." 

Gui,  Fab.  Hild. 

Felix  Wirtz  says,  that  the  elevation  of  the  cranium  in  shght  impressions  is 
needless.  "  Id  enim  motum  cerebri,  propter  vacuum  et  distantiam  quae  est 
"  inter  meningem  et  cranium,  minime  impedire."  And  Hildanus,  by  way  of 
reproof  to  what  Felix  Wirtz  says  :  "  Aliquando  duram  matrem  cranio  undique 
"  adliaerere  vidimus." 

Fallopius,  speaking  of  the  dura  mater,  says :  "  Continue  pulsat,  quare  non 
"  facile  sanatur." 

Petruse  Marchetti  supposed  the  dura  mater  always  to  be  at  a  distance  from 
tlie  scull  in  those  who  were  bald.  Speaking  of  the  treatment  of  a  particular 
case,  he  says  :  "  Post  septimam  nempe  oleum  hyperici,  quia  calvus  erat  pa- 
"  tiens  atque  membrana  a  calvaria  distabat;  quod  in  calvis  semper  observavi." 

Pet.  e  Marchetti  Obs.  Chir. 

"  Aliquando  contingit  ut  dura  mater  cranio  satis  firmiter  adbaereat,  sed  haec 
"  admodum  raro  evenire  solety  atque  prxter  nature  consuetudinem  est." 

Mttxs  Pmx.  Rat.  Chinirg. 

VOL.  I.  H 


58  INJURIES  OF  THE  HEAD 

most  eminent  practitioners,  was  the  principal  reason  why  the  bad 
effects  of  contusions  of  the  head  were  so  little  understood,  and  so 
grossly  mistreated  by  them.  They  supposed  that  the  vacuity  be- 
tween the  dura  mater  and  cranium  was  sufficient,  in  general, 
to  defend  the  former  from  all  external  violence;  and  the  blood  and 
matter  so  often  found  between  them  were  thought  to  be  deposited 
in  a  space  naturally  vacant.  Upon  this  principle  stood  both  their 
opinion  and  practice;  and  therefore  it  is  not  to  be  wondered  at, 
that  their  accounts,  in  general,  are  so  perplexed,  and  so  seldom 
verified  by  the  examination  of  dead  subjects. 

It  sometimes  happens,  that  the  scalp  is  so  wounded  at  the  time 
of  the  accident,  or  so  torn  away,  as  to  leave  the  bone  perfectly 
bare;  and  yet  the  violence  has  not  been  such  as  to  produce  the  evil 
I  am  now  speaking  of.  In  this  case,  if  the  pericranium  be  only 
turned  back,  along  with  the  detached  portion  of  scalp,  there  may 
be  probability  of  its  reunion,  and  it  should  therefore  be  imme- 
diately made  clean  and  replaced  for  the  purpose  of  such  experi- 
ment, which,  if  it  succeed,  will  save  much  time,  and  prevent  con- 
siderable deformity.  If  this  attempt  do  not  succeed,  the  detached 
piece  may  be  removed,  and  the  case  then  becomes  as  if  the  scalp 
and  the  pericranium  had  been  forced  away  at  the  time  that  the 
wound  was  first  inflicted;  and  the  worst  that  can  happen,  will  be 
an  exfoliation  from  the  bare  scull."^ 

This  was  also  the  opinion  of  Sylvius,  Pacchioni,  Ambrose  Pave,  Serjeaiit 
Wiseman,  Baglivi,  Barbette,  and  of  all  tliose  who  maintained  the  doctrine  of 
the  oscillation  of  the  dura  mater,  and  who  believed  that  that  membrane  was 
found  sometimes  liig-her,  sometimes  lower,  that  is,  sometimes  nearer  to, 
sometimes  farther  from  the  sculi,  at  one  age,  and  at  one  time  of  the  moon, 
than  another. 

'  Not  that  exfoliation  is  the  necessary  consequence  of  the  scull  being  laid 
bare  :  this  depends  upon  other  circumstances,  besides  the  mere  removal  of 
the  scalp  and  pericranium.  Tlie  solidity  of  the  surface  of  the  bones,  the  size 
of  the  vessels,  and  the  impulse  of  the  blood  through  them,  are  what  princi- 
pally determine  that.  If  the  cortex  of  the  bone  be  not  very  hard,  and  the 
impulse  of  the  blood  be  capable  of  counterbalancing  the  effects  of  the  exter- 
nal air,  a  granulation  of  flesh  will  be  generated  on  the  surface  of  the  bone, 
which  will  cover  and  firmly  adhere  to  it,  without  throwing  off  the  smallest 
exfoliation,  especially  in  young  subjects.  On  the  contrary,  if  the  bone  be 
much  hardened,  and  the  vessels  thereby  constringed  ;  or  if  such  apjilications 
be  made  use  of,  as  will  produce  an  artificial  constriction  of  them,  the  surface 


PROM  EXTERNAL  VIOLENCE.  59 

It  does  also  sometimes  happen,  that  the  force  which  detaches  or 
removes  the  scalp,  does  also  occasion  the  mischief  in  question;  but 
(he  integument  being  wounded,  or  removed,  we  cannot  have  the 
crilerion  of  the  tumour  of  the  scalp,  for  the  direction  of  our  Jjudg- 
ment.  In  these  circumstances,  our  whole  attention  must  (as  I 
have  already  said)  be  directed  to  the  wound  and  general  symp- 
toms: the  edges  of  the  former  will  (as  I  have  already  observed) 
digest  as  well,  and  look  as  kindly,  for  a  few  days,  as  if  no  mis- 
chief was  done  underneath;  but,  after  some  little  space  of  time, 
when  the  patient  begins  to  be  restless,  and  hot,  and  to  complain 
of  pain  in  the  head,  these  edges  will  lose  their  vermilion  hue,  and 
become  pale  and  flabby;  instead  of  matter  they  will  discharge  a 
thin  gleet,  and  the  pericranium  will  loosen  from  the  scull  to  some 
distance  from  the  said  edges:  immediately  after  this,  all  the  gene- 
ral symptoms  are  increased  and  exasperated;  and,  as  the  inflam- 
mation of  the  membrane  is  heightened,  or  extended,  they  become 
daily  worse  and  worse,  until  a  quantity  of  matter  is  formed,  and 
collected,  and  brings  on  that  fatal  period,  which,  though  uncertain 
as  to  date,  very  seldom  fails  to  arrive. 

The  method  of  attempting  the  relief  of  this  kind  of  injury  con- 
sists in  two  points,  viz.  to  end'eavour  to  prevent  the  inflammation 
of  the  dura  mater;  or,  that  being  neglected,  or  found  impracticable, 
to  give  discharge  to  the  fluid  collected  within  the  cranium,  in  con- 
sequence of  such  inflammation. 

Of  all  the  remedies  in  the  power  of  art,  for  inflammations  of 
membranous  parts,  there  is  none  equal  to  phlebotomy.  To  this 
truth  many  diseases  bear  testimony;  pleurisies,  ophthalmies,  stran- 
gulated hernias,  &c.:  and  if  any  thing  can  particularly  contribute 
to  the  prevention  of  the  ills  likely  to  follow  severe  contusions  of 
the  head,  it  is  this  kind  of  evacuation;  but  then  it  must  be  made- 
use  of  in  such  a  manner  as  to  become  truly  a  preventative,  that  is, 
it  must  be  made  use  of  immediately,  and  freely. 

I  am  very  sensible,  that  it  will  in  general  be  found  very  diffi- 
cult to  persuade  a  person,  who  has  had  what  may  be  called  only  a 

will  necessarily  become  dry,  and  tlie  juices  ceasing  to  circulate  through  it,  it 
must  part  w'lih  a  scale  to  a  certain  deptli ;  that  is,  that  part  of  the  surface 
through  which  the  circulation  ceases  to  be  carried  on  will  be  separated  frorBj 
and  cast  off  bv  the  vessels  \\  hich  nourish  the  rest  of  liie  bone. 


^''' 


60  INJURIES  OF  THE  HEAD 

knock  on  the  pate,  to  submit  to  such  discipline,  especially  if  he  lind 
himself  tolerably  well.  He  will  be  inclined  to  think,  that  the  sur- 
geon is  either  unnecessarily  apprehensive,  or  guilty  of  a  much 
worse  fault;  and  yet,  in  many  instances,  the  timely  use  or  the  ne- 
glect of  this  single  remedy,  makes  all  the  difference  between  safety 
and  fatality. 

It  may  be  said,  that  as  the  force  of  the  blow,  the  height  of  the 
fall,  the  weight  of  the  instrument,  &c.,  can  never  precisely  or  cer- 
tainly determine  the  effect,  nor  inform  us  whether  mischief  be 
done  under  the  bone  or  not,  a  large  quantity  of  blood  may  be 
drawn  off  unnecessarily,  in  order  to  prevent  an  imaginary  evil. 
This  is  in  some  degree  true;  and  if  the  advice  which  I  have  just 
given  were  universally  followed,  many  people  would  be  largely  bled 
without  necessity;  but  then,  on  the  other  hand,  many  a  very  valu- 
able life  would  be  preserved,  which,  for  Want  of  this  kind  of  as- 
sistance, is  lost.  "  Nihil  interest,  praesidium  an  satis  tutum  sit, 
"  quod  unicum  est,"  is  an  incontested  maxim  in  medicine;  and  if 
it  be  allowed  to  use  such  means  as  may  be  in  themselves  hazard- 
ous, surely  it  cannot  be  wrong  to  employ  one  which  is  not  so;  at 
least,  if  it  be  considered  in  a  general  sense,  whatever  it  may  acci- 
dentally prove  to  some  few  particular  individuals. 

Acceleration,  or  hardness  of  pulse,  restlessness,  anxiety,  and 
any  degree  of  fever,  after  a  smart  blow  on  the  head,  are  always  to 
be  suspected  and  attended  to.  Immediate,  plentiful,  and  repeated 
evacuation  by  bleeding,  have,  in  many  instances,  removed  these, 
in  persons  to  whom,  I  do  verily  believe,  very  terrible  mischief 
would  have  happened,  had  not  such  precaution  been  used.  In 
this,  as  well  as  some  other  parts  of  practice,  we  neither  have,  nor 
can  have  any  other  method  of  judging,  than  by  comparing  together 
cases  apparently  similar.  I  have  more  than  once  or  twice  seen 
that  increased  velocity  and  hardness  of  pulse,  and  that  oppressive 
languor,  which  most  frequently  precede  mischief  under  the  bone, 
removed  by  free  and  repeated  blood-letting;  and  have  often,  much 
too  often,  seen  cases  end  fatally,  whose  beginnings  were  full  as 
plight,  but  in  which  such  evacuation  had  been  either  neglected  or 
not  complied  with. 

I  would  by  no  means  be  thought  to  infer  from  hence,  that  early 
bleeding  will  always  prove  a  certain  preservative,  and  that  they 


FROM  EXTERNAL  VIOLENCE.  61 

only  die  to  whom  it  has  not  been  applied:  this,  like  all  other  hu- 
man means,  is  fallible;  and  perhaps  there  are  more  cases  out  of 
its  reach,  than  within  it;  but,  where  preventative  means  can  talcQ 
place,  this  is  certainly  the  best,  and  the  most  frequently  success- 
ful. 

The  second  intention,  viz.  for  procuring  the  discharge  of  matter 
collected  under  the  cranium,  can  be  answered  only  by  the  perfo- 
ration of  it. 

When,  fiom  the  symptoms  and  appearances  already  described, 
there  is  just  reason  for  supposing  matter  to  be  formed  under  the 
scull,  the  operation  of  perforation  cannot  be  performed  too  soon; 
it  seldom  happens  that  it  is  done  soon  enough.* 

The  propriety  or  impropriety  of  applying  the  trephine,  in  cases 
where  there  is  neither  fissure,  fracture,  nor  symptom  of  extrava- 
sation, is  a  point  which  has  been  much  litigated,  and  remains  still 
unsettled  either  by  writers  or  practitioners. 

When  there  is  no  reason  for  suspecting  any  of  those  injuries, 
either  from  the  symptoms,  or  from  the  appearances;  and  the  peri- 
cranium, whether  the  scalp  be  wounded  or  not,  remains  firmly  at- 
tached in  all  parts  to  the  scull;  there  certainly  is  not  (let  the 
general  symptoms  be  what  they  may)  any  indication  where  to 
apply  the  instrument,  and  consequently  no  sufficient  authority  for 
using  it  at  all:  but  whenever  that  membrane,  after  the  head  has 
received  an  external  violence,  separates,  or  is  detached  spontane- 
ously from  the  bone  underneath  it,  and  such  separation  is  attended 
with  the  collection  of  a  small  quantity  of  thin,  brown  ichor,  an 
alteration  of  colour  in  the  separated  pericranium,  and  an  unna- 
tural dryness  of  the  bone,  I  cannot  help  thinking,  that  there  is  as 
good  reason  for  trepanning,  as  in  the  case  of  fracture;  I  believe 
experience  would  vindicate  me,  if  I  said,  better  reason;  since  it 
is  by  no  means  infrequent  for  the  former  kind  of  case  to  do  well 
without  such  operation,  whereas  the  latter  (I  mean  suppuration 
under  the  scull)  never  can.* 

s  "  His,  ubi  cito  manus  admoveatur,  salutis  aliqua  spes  subest ;  ubi  serius, 
"  plerique  otnnes  moriuntur." 

Ahchigewes. 

t  Les  auteurs  jusqii'ici  ne  nous  ont  parle  du  trepan  qa'autant  qu'il  pouvoit 
servir  a  relever  des  pieces  du  crane  enfoncees  par  un  coup  violent,  ou  » 


62  INJURlliS  OF  THE  HEAD 

All  the  best  practitioners  have  always  agreed  in  acknowledging 
the  necessity  of  perforating  the  scull  in  case  of  a  severe  stroke 
piade  on  it  by  gun-shot,  upon  the  appearance  of  any  threatening 
symptoms,  even  though  the  bone  should  not  be  broken;  and  very 
good  practice  it  is.  A  wound  by  gun-shot  (as  far  as  it  relates  to 
the  scull)  is  to  be  regarded  only  as  one  attended  with  a  very  high 
degree  of  contusion,  and  therefore  most  likely  to  produce  symp- 
toms accordingly;  among  which,  inflammation  of  tiie  dura  mater 
stands  principal.  Experience  confirms  both;  most  of  the  symp- 
toms attending  wounds  of  the  head,  made  by  gun-shot,  are  symp- 
toms of  contusion;  and  the  formation  of  matter  between  the 
cranium  and  dura  mater  is  a  very  frequent  and  a  very  fatal  con- 
sequence of  such  contusion. 

In  short,  the  spontaneous  separation  of  the  pericranium,  if  at- 
tended with  general  disorder  of  the  patient,  with  chilness,  horri- 
pilatio,  languor,  and  some  degree  of  fever,  appears  to  me,  from 
all  the  observation  I  have  been  capable  of  making,  to  be  so  sure 
and  certain  an  indication  of  mischief  underneath,  either  in  pre- 
sent, or  impending,  that  I  should  never  hesitate  about  perforating 
the  bone  in  such  circumstances. 

When  the  scull  has  been  once  perforated,  and  the  dura  mater 
thereby  laid  bare,  the  state  of  the  latter  must  principally  deter- 
mine the  surgeon's  future  conduct.  In  some  cases,  one  opening 
will  prove  sufficient  for  all  necessary  purposes,  in  others  several 
may  be  necessary.  This  variation  will  depend  on  the  space  of 
detached  dura  mater,  and  the  quantity  of  collected  matter.  The 
repetition  of  the  operation  is  warranted,  both  by  the  nature  of  the 
case,  and  by  the  best  authorities;  there  being  no  comparison  to  be 
made  between  the  possible  inconvenience  arising  from  largely  de- 
nuding the  dura  mater,  and  the  certain  as  well  as  terrible  evils 
which  must  follow  the  formation  and  confinement  of  matter  be- 
tween it  and  the  scull. 

donii6  issue  a  quelque  liqueui",  comme  seroit  du  sang,  ou  du  pus,  epanclie, 
sous  le  crane. 

La  contusion  de  I'os  est  un  cas,  oii  le  trepan  n'est  pas  moins  necessaire  ; 
lion  a  cause  que  I'os  est  contus,  mais  pour  prevenir  la  maladie  de  la  dure 
mire,  et  de  la  pie  mere;  qui  en  estune  suite  presque  indispensable. 

Le  Dean, 


FROM  EXTERNAL  VIOLENCE.  63 

It  can  hardly  be  necessary  for  me  to  observe,  to  whoever  re- 
flects ever  so  little  on  the  true  nature  of  these  cases,  that  notwith- 
standing the  operation  of  perforation  be  absolutely  and  unavoid- 
ably necessary,  yet  the  repetition  of  blood-letting,  of  cooling  laxa- 
tive medicines,  the  use  of  antiphlogistic  remedies,  and  a  most 
strict  observance  of  a  low  diet  and  regimen,  are  as  indispensably 
requisite  after  such  operation  as  before;  the  perforation  sets  the 
membrane  free  from  pressure,  and  gives  vent  to  collected  matter, 
but  nothing  more;  the  inflamed  state  of  the  parts  under  the 
scull,  and  all  the  necessary  consequences  of  such  inflammation, 
call  for  all  our  attention,  full  as  much  afterwards  as  before;  and 
although  the  patient  must  have  perished  without  the  use  of  the 
trephine,  yet  the  merely  having  used  it  will  not  preserve  him, 
without  every  other  caution  and  care. 

This  being  all  that  our  art  is  capable  of  doing  in  these  melan- 
choly cases,  I  wish  I  could  say,  that  it  was  most  frequently  suc- 
cessful. Sometimes  it  is:  the  operation,  considered  abstractedly, 
is  not  in  itself  hazardous,  and  is  the  unicum  remediwn  for  the  most 
immediately -impending  and  most  threatening  mischief:  some  have 
been  saved  by  it,  none  can  escape  without  it.  As  there  are  no 
certain  indications,  no  criteria^  whereby  we  are  enabled  to  judge 
whether  it  will  prove  successful  or  not,  the  event  of  each  indi- 
vidual case  can  alone  determine.  When  that  is  happy,  the  means 
are  very  justly  commended;  but  when  it  is  not  so,  they  ought  not 
therefore  to  be  condemned;  since  they  are  built  on  rational  prin- 
ciples, and  are  the  only  means  in  human  power. 


CASE  I. 

A  POOR  fellow  crossing  Tower-hill,  got,  before  he  was  aware 
of  it,  into  a  mob,  that  was  endeavouring  to  rescue  a  sailor  from  a 
press-gang.  The  man  was  knocked  down.  When  the  crowd 
dispersed,  he  was  found  senseless,  and  in  that  state  was  brought 
to  St.  Barthoiomew's  hospital,  where  he  was  immediately  let 
blood,  and  put  to  bed.  In  an  hour  or  two,  he  was  so  recovered,  as 
to  be  able  to  give  the  preceding  account. 

When  Mr.  Nourse  (whose  week  it  was  for  accidents)  saw  him 


64  INJURIES  OF  THE  HEAD 

the  next  day,  the  man  appeared  to  be  perfectly  well,  nor  did  any 
mark  of  violence  appear  on  his  head,  except  one  small  bruise,  and 
that  so  slight,  that  it  might,  with  more  probability,  be  attributed 
to  the  fall  than  the  blow.  However,  as  he  was  positive  that  he 
had  been  knocked  down,  by  a  very  smart  blow,  from  a  heavy 
weapon;  and  as  he  certainly  had  been  deprived  of  sense  a  con- 
siderable time  thereby;  Mr.  Nourse  bled  him  again,  and  ordered 
him  to  be  kept  in  bed,  and  to  a  very  low  diet.  At  the  end  of 
three,  days  the  man  found  himself  so  well,  as  to  leave  the  hospital, 
and  go  to  work.  On  the  twelfth  day  from  that  of  the  accident, 
he  came  to  my  surgery,  and  complained  of  being  much  out  of 
order;  said  that  his  head  was  very  uneasy;  that  he  was  hot,  thirsty, 
got  little  or  no  sleep,  and  was  at  times  so  faint  that  he  could  not 
pursue  his  labour.  He  looked  ill,  assured  me  he  had  lived  very 
soberly  from  the  time  of  his  leaving  the  hospital,  and  that  he  had 
been  in  his  present  state  for  three  days  past.  I  took  him  into  the 
house  again,  bled  him,  ordered  him  a  clyster  immediately,  and  that 
he  should  be  kept  in  bed. 

Next  day  (13th)  he  was  in  much  the  same  state  a&  the  preced- 
ing; he  had  passed  a  restless  night,  had  dosed  now  and  then,  but 
awoke  with  much  disturbance.  He  had  a  hot  skin,  and  a  flushed 
countenance,  mixed  with  a  light  yellow  tint;  he  complained  of 
general  pain  and  tightness  all  over  his  head,  but  neither  to  the 
sight  nor  to  the  touch  was  there  any  appearance,  or  sensation, 
whereon  to  build  a  probable  supposition  of  particular  mischief. 
He  was  again,  by  the  physician's  order,  let  blood,  and  directed  to 
take  the  sal  absinthii  mixture,  with  a  few  grains  of  rhubarb  in  it, 
every  six  hours.  He  passed  the  ensuing  night  in  a  disturbed 
manner,  and  the  next  day  (the  14th)  was  apparently  worse;  his 
skin  was  hotter,  his  pulse  quicker,  and  his  pain  more  acute;  he 
also  now  thought,  that  one  part  of  his  head  was  tender  to  the 
touch,  and  said,  he  was  sure  that  was  the  part  that  received  the 
blow.  This  place  I  examined.  The  scalp  did  seem  to  be  rather 
fuller  than  natural,  but  by  no  means  sufficiently  so  to  enable  me  to 
form  any  judgment  by.  Toward  the  close  of  this  day  he  had  a 
slight  shivering,  was  sick,  and  vomited,  and  passed  the  following 
night  without  any  sleep  at  all;  talking  sometimes  incoherently, 
but  still  capable  of  giving  a  rational  answer  to  any  question  which 


FROM  EXTERNAL  VIOLENCE.  UO 

engaged  his  attention.  On  the  15th  day,  the  tumor  of  the  scalp 
was  more  apparent,  but  yet  seemed  to  contain  little  or  no  fluid,  and 
was  about  the  breadth  of  a  crown  piece.  I  would  have  removed 
that  portion  of  scalp;  but  while  I  was  intending  it,  the  poor  man 
bad  a  very  severe  rigor,  which  disordered  him  so  much,  that  he 
begged  to  be  let  alone  for  the  present.  That  afternoon  he  had 
two  more  shiverings,  passed  very  ill  the  following  night,  and  next 
morning  was  delirious.  The  tumor  now  was  more  risen,  con- 
tained palpably  a  fluid,  but  was  by  no  means  tense;  I  took  away 
the  whole  tumid  piece,  by  a  circular  incision,  gave  discharge  to  a 
thin  brown  sanies,  and  found  the  cranium  perfectly  naked,  altered 
considerably  in  colour  from  that  of  a  healthy  natural  one,  but  with- 
out fissure,  fracture,  or  other  evil.  That  whole  night  and  next 
day  he  was  delirious;  his  skin  burning  hot;  he  had  frequent  spasms, 
which  shook  his  whole  frame,  and  the  next  night  (the  17th)  he 
died. 

The  whole  scalp,  except  round  the  edge  of  the  incision,  was  in 
a  natural  state;  the  pericranium  in  every  other  part,  except  the  tu- 
mid one,  adhered  to  the  bone;  and  neither  inflammation,  nor  tumor 
of  any  kind,  all  over  the  rest  of  the  head.  Under  that  part  of  tli,e 
scull  from  which  the  pericranium  had  been  detached,  and  from 
which  the  scalp  had  been  removed,  a  very  considerable  collection 
of  matter  was  found  lying  between  the  dura  mater  and  cranium, 
but  no  appearance  of  disease  any  where  else. 


CASE  II. 

CONTUSION  WITH  WOUND. 

A  YOUNG  fellow,  playing  at  quoits,  was  struck  down  by  the 
perpendicular  fall  of  one  of  them  on  his  head.  It  made  a  large 
wound,  which  bled  freely,  but  did  not  divide  the  pericranium, 
and  consequently  did  not  denude  the  scull.  The  wound  was 
brought  together  by  a  stitch  made  by  somebody  at  hand;  and  the 
man,  though  stunned  at  first  by  the  blow,  having  vomited  plenti- 
fully, was  soon  well,  and  the  next  day  went  to  his  work,  which 
was  that  of  a  farrier.     The  wound  was  dressed  daily  with  a  su- 

TOL.  I.  I 


66  INJURIES  OF  THE  HEAD 

perficial  pledget,  by  the  person  who  first  saw  and  stitched  it;  and 
it  seemed  to  unite  kindly. 

On  the  sixth  day  from  that  of  the  accident,  he  complained  of 
being  chilly  and  faint;  and  when  he  had  done  about  half  a  day's 
work,  found  himself  unable  to  bear  the  heat  of  the  forge,  or  to 
stoop  to  shoe  a  horse,  on  account  of  pain  in  his  head;  he  there- 
fore left  his  shop,  went  home,  and  sent  for  the  apothecary  who 
first  had  dressed  him.  The  wound,  not  being  very  carefully  exa- 
mined, appeared  to  be  healed,  and  therefore  was  not  regarded  as 
any  cause  of  the  man's  present  indisposition,  who  was  treated  as 
having  a  fever  from  cold  and  irregularity:  he  was  let  blood,  and 
took  some  medicines;  but  at  the  end  of  three  days  (nine  from  the 
accident)  being  worse,  and  incapable  of  bearing  the  expense  of 
remaining  at  home,  he  was  brought  to  St.  Bartholomew's  hospi- 
pital.  On  the  tenth  day  from  that  on  which  he  was  wounded,  I 
saw  him.  He  had  a  considerable  degree  of  fever;  his  pulse  was 
hard  and  quick,  his  skin  hot  and  dry,  his  face  flushed,  his  eye 
languid,  and  he  complained  of  great  pain  and  tightness  all  over 
his  head.  The  wound  was  apparently  but  not  really  healed;  I 
could  pass  a  probe  underneath,  from  one  end  to  the  other  of  it; 
and  I  could  feel  the  cranium  bare  the  whole  way.  I  divided  its 
whole  length;  found  the  pericranium  sloughy,  and  detached  to  a 
considerable  distance,  and  the  bone  much  altered  in  colour;  upon 
sight  of  which,  I  removed  the  whole  separated  part,  by  a  large 
circular  incision. 

From  the  symptoms  and  appearances  I  prognosticated  no  good. 
He  was  again  let  blood,  and  had  a  clyster,  and  a  lenient  purge, 
which  together  produced  three  stools.  That  night  (the  10th)  he 
had  a  rigor,  after  which  his  pain  became  more  intense,  and  fever 
higher. 

The  next  morning  (the  11th)  he  had  another  shivering;  and 
when  I  saw  him  about  noon,  he  was  very  inconsistent.  I  set  on 
a  trephine  close  to  the  sagittal  suture  on  one  side;  and  gave  dis- 
charge to  a  small  quantity  of  matter  which  lay  on  the  surface  of 
the  dura  mater;  after  being  lightly  dressed,  some  more  blood  was 
drawn  from  one  of  the  jugular  veins,  and  he  was  ordered  to  take 
a  draught  of  the  salt  of  wormwood  mixture  frequently.  The  next 
day  (the  12th)  he  was  worse.     I  therefore  set  the  trephine  on 


FROM  EXTERNAL  VIOLENCE.  67 

again,  but  on  the  other  side  of  the  suture,  and  by  that  means  let 
out  a  considerable  quantity  of  matter  from  between  the  scull  and 
membrane.  Soon  after  this  he  became  more  rational,  and  seemed 
to  get  a  little  sleep;  but  in  the  evening  his  pain  returned  with 
great  violence,  and  he  had  a  rigor  which  held  him  above  an  hour.. 

When  I  saw  him  the  next  day  (the  13th)  he  was  senseless,  had 
a  low  faltering  pulse,  and  a  profuse  cold  sweat;  soon  after  which 
he  expired. 

Upon  removing  the  upper  part  of  the  scull,  a  large  quantity  of 
matter  was  found  Imder  each  parietal  bone,  which  had  detached 
the  dura  mater  from  its  connexion  with  the  scull  for  a  considera- 
ble space,  but  not  at  the  suture.  On  the  right  side  a  portion  of 
the  dura  mater  was  become  sloughy,  about  the  breadth  of  a  shil- 
ling; and  under  this  altered  part  was  matter  between  the  two 
meninges. 

The  more  firm  attachment  of  the  dura  mater  at  the  sutures, 
renders  the  separation  of  it  at  these  places  very  difficult:  which 
circumstance,  added  to  the  consideration  of  the  situation  of  the 
sagittal  suture  on  the  very  top  of  the  head,  renders  the  application 
of  the  trephine  on  each  side  of  it  often  absolutely  necessary.  For 
if  there  be  good  reason  to  suspect  either  an  extravasation  of  blood, 
or  a  collection  of  matter  in  consequence  of  a  blow  received  on 
this  suture,  and  one  side  only  be  perforated,  the  operation  may 
happen  to  be  performed  on  that  side  where  the  blood  or  matter 
does  not  lie,  and  will  therefore  be  successless;  or,  on  the  other 
hand,  the  extravasation  or  suppuration  may  be  on  both  sides;  and 
then  the  perforation  of  one  only  cannot  answer  the  whole  pur- 
pose, and  the  patient  will  as  certainly  perish  as  if  nothing  had 
been  done  at  all. 


CASE  III. 

CONTUSION  WITHOUT  WOUND. 

A  BOY  about  nine  years  old,  playing  under  an  empty  cart,  whose 
shafts  were  supported  by  a  stick,  was  knocked  down  by  the  fall 
of  one  of  them  upon  his  head.    The  child  was  stunned  by  the 


68  INJURIES  OP  THE  HEAD 

blow  for  a  minute  or  two,  but  soon  became  sensible.  When  he 
came  home,  there  being  a  small  swelling  where  the  blow  had 
been  stricken,  his  mother  applied  a  bit  of  linen  rag,  wet  with 
vinegar;  and  as  he  appeared  to  be  perfectly  well,  in  a  day  or  two 
he  was  sent  to  school. 

Five  days  passed  over  before  he  made  any  complaint:  on  the 
sixth,  he  said  that  his  head  ached;  he  brought  up  his  breakfast, 
and  could  eat  no  dinner;  but  in  the  evening  seemed  to  be  pretty 
well  again.  On  the  7th  he  complained  still  more  of  his  head, 
and  said  that  he  was  very  sick  and  very  cold.  He  was  put  to 
bed,  but  got  no  rest.  As  he  had  not  had  either  small-pox  or 
measles,  he  was  brought  home,  and  treated  as  if  one  of  these  dis- 
eases was  to  follow. 

Three  days  more  passed,  and  no  eruption  appeared:  the  fever 
continued  much  the  same;  he  was  frequently  inclined  to  vomit; 
and  what  little  sleep  he  got,  was  extremely  disturbed.  He  was, 
by  the  order  of  a  physician,  let  blood,  had  a  blister  applied  to  his 
back,  and  took  some  of  the  common  febrifuge  medicines.  On 
the  12th  day  from  that  of  the  accident,  he  was  seized  with  a 
shivering,  which  held  him  more  than  a  quarter  of  an  hour;  after 
which  his  pain  became  more  acute  and  his  fever  higher.  Some 
blood  was  drawn  from  his  temples  by  leeches,  and  he  was  order- 
ed some  other  medicines.  On  the  13th  at  noon,  he  had  another 
rigor,  still  more  severe  than  the  former,  and  of  longer  duration; 
and  that  evening  he  became  light-headed.  By  some  means  or 
other,  the  accident  of  the  blow  was  now  mentioned  to  the  person 
who  attended  him,  and  who  desired  that  a  surgeon  might  look  at 
his  head.  I  found  about  a  third  part  of  the  left  parietal  bone  co- 
vered by  a  flattish  tumor,  containing  a  fluid. 

From  the  appearance  of  this  swelling,  from  the  date  of  the  ac- 
cident, the  attack,  violence,  and  duration  of  the  symptoms,  I  made 
no  scruple  to  give  my  opinion,  that  the  blow  had  been  the  sole 
cause  of  all  the  child's  illness;  that  I  suspected  the  scull  under 
the  tumor  to  be  bare,  if  not  injured;  that  I  did  also  believe,  that 
matter  was  forming,  or  formed,  under  the  scull;  and  that  if  the 
last  conjecture  was  true,  the  only  chance  the  child  could  have  of 
preservation,  must  be  from  the  operation  of  the  trephine. 

The  scalp  was  divided,  and  the  scull  found  as  I  suspected,  that 


PROM  EXTERNAL  VIOLENCE.  69 

is,  perfectly  bare,  and  altered  from  a  natural  colour:  I  would  there- 
fore have  perforated  it  immediately;  but,  as  the  bone  was  not 
broken,  the  parents  objected  to  such  operation;  and  the  physical 
gentleman,  who  had  the  care  of  the  boy,  not  having  seen  much 
business  of  this  kind,  and  not  rightly  comprehending  the  true  na- 
ture of  the  case,  joined  in  opinion  with  the  parents,  that  such  ope- 
ration was  not  necessary.  It  was  therefore  not  performed,  and 
the  whole  was  committed  to  internal  remedies. 

The  fever  increased,  and  the  child's  strength  decreased  in  pro- 
portion: he  continued  delirious  for  three  days  more,  then  sank  into 
a  state  of  insensibility,  and  died. 

Having  been  contradicted,  and  (as  I  thought)  somewhat  im- 
properly over-ruled  in  the  management  of  the  patient  while  alive, 
I  was  the  more  importunate  to  get  leave  to  examine  him  when 
dead. 

All  that  part  of  the  dura  mater  which  bad  been  covered  by  the 
left  parietal,  and  part  of  the  temporal  bone,  was  detached  from  the 
said  bones,  and  covfered  with  a  considerable  quantity  of  matter. 
Under  the  middle  part  of  the  former  bone  the  dura  mater  was 
discoloured  and  sloughy;  this  discoloured  part  I  opened  with  a 
lancet,  and  let  out  near  a  spoonful  of  matter,  which  matter  lay 
between  the  meninges.  All  the  rest  of  the  contents  of  the  head 
were  unaffected. 

When  first  I  saw  this  child,  all  chance  of  relief  from  evacuation 
was  over,  and  his  symptoms  plainly  indicated  mischief  under  the 
scull.  Nothing,  therefore,  but  perforation  could  give  him  any  kind 
of  chance. 

I  do  not  say  that  this  operation  would  have  saved  him;  I  am 
much  inclined  to  believe  that  it  would  not;  but  still  it  was  the  only 
thing  that  could  with  propriety  have  been  done  for  him;  and  tliere- 
fore  it  ought  to  have  been  done,  instead  of  wasting  time  with  the 
use  of  internal  remedies,  from  which  no  possible  good  could  be 
expected  or  derived. 


TO  INJURIES  OF  THE  HEAD 


CASE  IV. 


CONTUSION  WITHOUT  WOUND. 


A  LABOURING  man  fell  from  a  scaffold,  two  stories  high,  by 
which  he  was  for  a  few  minutes  stunned  and  insensible,  but  soon 
recovered.  He  was  let  blood;  and,  having  bruised  his  right  arm, 
and  the  same  side  of  his  forehead,  he  was  properly  dressed  by 
somebody  in  the  neighbourhood. 

Next  day,  being  very  well,  he  returned  to  his  labour,  and  fol- 
lowed it  daily  for  five  more.  On  the  sixth,  finding  himself  a  good 
deal  out  of  order, "he  came  to  the  hospital  for  advice.  He  com- 
plained of  shooting  and  frequent  pain  in  his  head;  of  giddiness, 
and  inclination  to  vomit;  and  said,  that  he  felt  as  if  a  cord  was 
drawn  tight  round  his  brain.  On  the  right  side  of  his  forehead 
was  a  small  tumor,  neither  tense  nor  painful,  but  palpably  con- 
taining a  fluid.  I  persuaded  the  man  to  let  me  open  it.  I  found 
a  small  quantity  of  a  brown  fluid,  covering  the  bone,  perfectly  de- 
nuded of  its  periosteum;  upon  which  discovery,  I  removed  the 
whole  piece  by  a  circular  incision:  fourteen  ounces  of  blood  were 
drawn  from  his  arm;  a  clyster  was  thrown  up,  and  he  was  con- 
fined to  his  bed,  and  barley-water. 

Next  morning  (the  seventh)  his  pulse  was  full,  hard,  and  fre- 
quent; he  had  slept  very  little,  and  that  in  a  very  disturbed  manner. 
He  was,  by  the  physician's  order,  let  blood  again,  and  directed  to 
take  the  sal  absinthii  mixture,  with  rhubarb  sextis  horis.  On  the 
eighth  day,  he  was  let  blood  again  from  one  of  the  jugulars,  and 
being  rather  still  costive,  took  a  gentle  purge.  On  the  ninth,  his 
pulse  was  still  higher  and  harder,  and  his  skin  more  hot  and  dry; 
twelve  ounces  more  of  blood  were  drawn  off  from  one  of  the  tem- 
poral arteries.  That  evening  he  had  a  shivering,  after  which  he 
complained  that  his  pains  were  much  increased.  Next  morning 
(the  tenth)  his  sore  looked  very  ill:  was  pale,  spongy,  and  glassy, 
and  the  scalp  separated  from  the  scull  to  some  distance  beyond 
the  edges  of  the  wound.  1  set  on  a  trephine,  and  removed  a  piece 
of  the  cranium,  under  which  the  dura  mater  was  smeared  over 


FROM  EXTERNAL  VIOLENCE.  *i  I 

with  matter,  and  had  lost  its  bright  colour.  That  night  he  got  no 
sleep,  and  toward  morning  had  another  rigor. 

The  eleventh,  at  noon,  he  was  manifestly  worse  in  every  re- 
spect; his  pain  was  intense,  his  fever  high,  and  his  sore  as  ill- 
conditioned  as  possible.  With  the  largest  trephine  I  had,  I  took 
away  another  piece  of  the  cranium,  nearer  to  the  temporal  bone, 
and,  by  means  of  this  opening,  procured  the  discharge  of  a  consi- 
derable quantify  of  matter.  This  done,  finding  his  pulse  still  high 
and  full,  I  drew  off  ten  ounces  more  of  blood,  and  ordered  him  a 
clyster.  The  loss  of  blood  produced  a  swooning,  which  lasted  some 
minutes,  after  which,  he  said  that  he  thought  his  head  was  rather 
easier.  As  the  evening  approached,  his  pain  returned,  wherefore 
some  leeches  were  applied  to  his  temples.  That  night  he  got  a 
little  quiet  sleep,  and  in  the  morning  of  the  twelfth  day  said  that 
his  head  was  perfectly  easy:  a  very  large  discharge  of  matter  had 
been  made  through  the  perforation  in  the  cranium,  and  I  thought 
that  the  wound  of  the  scalp  wore  rather  a  better  aspect.  He  was 
kept  strictly  to  a  proper  low  regimen;  took  at  first  the  sal  absinthii 
mixture  freely;  when  his  pain  had  left  him,  the  physician  ordered 
him  the  bark;  and,  in  a  very  kw  days,  every  bad  symptom  and  ap- 
pearance left  him. 

Would  not  this  case,  which  ended  so  happily,  have  been  at- 
tended withjhe  most  fatal  consequences,  if  the  free  perforation 
of  the  scull  had  been  omilted,  or  if  less  blood  had  been  drawn 
off? 


CASE  V. 

eONTUSION  WITH  WOUND. 

A  YOUNG  fellow  of  about  twenty  years  was  thrown  from  an  un- 
ruly horse  against  one  of  the  rails  in  Smithfield.  The  blow  was 
great;  he  lay  senseless  for  above  an  hour,  and  in  that  state  was 
brought  into  St.  Bartholomew's  hospital. 

He  had  a  large  wound  on  one  side  of  his  forehead,  the  skin  of 
which  which  was  partly  torn  guite  off,  and  partly  turned  down 


73  INJURIES  OF  THE  HEAD 

over  his  eye.  The  lips  of  the  wound  were,  by  ijie  person  who 
saw  him  first,  brought  as  near  together  as  they  would  admit,  but 
such  a  portion  was  lost,  as  necessarily  left  the  bone  bare  about 
the  breadth  of  a  shilling.  As  soon  as  his  wound  had  been  ex- 
amined, he  was  let  blood  and  put  to  bed.  The  next  day,  his  pulse 
being  hard  and  full,  he  was  again  let  blood,  and  was  ordered  to 
have  a  clyster,  a  lenient  purge,  and  some  febrifuge  medicines. 
On  the  third,  the  wounded  scalp,  and  that  side  of  the  face  being 
much  swollen,  a  warm  cataplasm  was  applied  over  the  dressings, 
and  the  part  was  well  fomented;  and,  in  about  five  days  more, 
every  thing  wore  so  good  an  aspect,  that  the  man  seemed  to  be 
getting  well  apace.  On  the  ninth,  he  complained  of  being  out  of 
order,  said  his  head  ached,  and  that  he  had  not  slept  the  preceding 
night.  He  was  hot  and  feverish,  and  his  pulse  hard  and  full.  He 
was  therefore  let  blood  again,  and  ordered  to  have  a  clyster,  and  to 
be  kept  very  low.  On  the  tenth,  in  the  night,  he  had  (as  he  called 
it)  a  chilliness  which  came  all  over  him;  after  which  his  pain  was 
considerably  increased.  On  the  eleventh,  his  sore  seemed  to  spread, 
discharged  a  thin  gleet  instead  of  matter,  the  lint  with  which  it 
was  dressed  stuck  fast  to  all  parts  of  it;  and  its  surface,  from  hav- 
ing been  florid  and  granulated,  became  tawny  and  spongy.  That 
day  he  had  another  shivering;  and,  on  the  next,  being  the  twelfth, 
a  consultation  was  held  on  him.  He  was  now  very  hot  and  fe- 
verish; his  face  much  flushed,  an  erysipelas  beginning  to  appear 
on  his  eye-lids,  his  sore  very  ill-conditioned,  and  the  bare  bone  so 
much  changed  from  its  natural  colour,  that  it  looked  as  if  matter 
might  have  been  seen  through  it.  Consideratis  considerandis,  it 
was  agreed  that  he  had  no  chance  for  his  life  but  by  perforation  of 
the  bare  cranium.  The  operation  was  immediately  performed, 
and  a  quantity  of  matter  found  on  the  dura  mater.  For  several 
days  the  discharge  was  great,  and  the  man  continued  very  ill;  but 
about  the  eighteenth  day  the  fever  left  him,  he  became  easy,  the 
discharge  lessened,  his  sore  put  on  a  good  face,  and  he  got  a  na- 
tural sleep.  From  this  time  nothing  sinister  happened,  and  the 
man  got  soon  well. 


FROM  EXTERNAL  VIOLENCE-  73 

CASE  VI. 

CONTUSION  WITHOUT  WOUND. 

A  LAD  about  twelve  years  old,  standing  by  a  man  who  was  play- 
ing at  cricket,  received  a  blow  from  the  bat  on  his  forehead.  The 
boy  became  senseless,  and  as  he  was  not  known  to  any  body  pre- 
sent, he  was  brought  to  the  hospital.  He  recovered  his  senses  be- 
fore he  got  thither;  but  the  part  which  received  the  stroke  being 
much  swollen,  he  was  dressed,  let  blood,  and  ordered  to  keep  in 
bed.  When  I  saw  him  next  morning,  he  had  no  complaint  but 
the  soreness  of  his  forehead,  under  the  skin  of  which  there  seemed 
to  be  a  good  deal  of  extravasated,  coagulated  blood.  His  pulse 
was  full  and  strong;  he  was  therefore  again  let  blood;  and  as  he 
had  not  had  a  stool  for  two  days,  a  clyster  was  thrown  up,  and  a 
lenient  purge  given.  A  discutient  cerate  was  kept  upon  his  fore- 
head; and,  being  of  a  costive  habit,  he  was  purged  once  in  two  or 
three  days;  and,  on  the  ninth  from  that  of  the  accident,  was  dis- 
charged from  the  house.  On  the  fourteenth,  he  returned  to  it 
again,  complained  of  lassitude,  giddiness,  and  head-ach.  He  was 
put  under  the  care  of  the  physician,  was  let  blood,  vomited,  purged, 
and  took  proper  medicines,  but  remained  much  the  same  for  three 
or  four  days;  that  is,  he  was  feverish,  with  a  skin  toohot,  a  pulse 
too  quick,  and  what  little  sleep  he  got  was  unquiet  and  short.  On 
the  seventeenth  day  he  had  a  slight  rigor,  during  and  after  which 
his  pain  in  the  head  was  much  more  intense;  and  the  following 
day  all  his  febrile  symptoms  were  much  exasperated.  On  the 
nineteenth,  he  complained  of  tenderness  to  the  touch  on  his  fore- 
iiead,  and  great  general  pain  in  his  head.  He  was  again  let  blood, 
and  was  more  sunk  by  the  discharge  than  I  could  have  supposed, 
but  no  remission  of  his  symptoms  followed.  His  sleep  that  night 
was  very  little,  and  very  unquiet;  toward  morning  he  had  two 
distinct  shiverings;  and  when  I  saw  him  at  noon,  oil  the  twentieth, 
his  forehead  appeared  somewhat  tumid  and  pufiR'.  From  the  con- 
tinuance and  exasperation  of  his  symptoms,  and  from  the  new  ap- 
pearance on  his  forehead,  I  was  almost  certain  there  was  mischief 

VOL,  I.  K  ■ 


74  INJURIES  OF  THE  HEAO 

on  or  under  the  scull;  I  therefore  divided  the  scalp,  to  examine  the 
bone,  and  found,  between  it  and  the  pericranium,  which  had  quit- 
ted its  adhesion  for  more  than  the  breadth  of  a  crown  piece,  a 
small  quantity  of  a  thin,  discoloured  fluid. 

This  (as  it  appeared  to  me)  put  the  nature  of  the  case  out  of 
doubt,  and  left  the  boy  no  chance,  but  from  perforation.  I  there- 
fore applied  the  trephine  immediately,  and  gave  discharge  to  mat- 
ter formed  between  the  dura  mater  and  bone.  For  a  week  after 
the  operation,  the  discharge  was  large,  and  the  boy  in  much 
hazard;  but,  at  the  end  of  that  time,  the  suppuration  lessened,  the 
dura  mater  incarned  kindly,  and  by  proper  care,  and  taking  freely 
of  the  decoct,  cortic.  Peruv.  he  got  well. 


CASE  VII. 

CONTUSION  WITHOUT  WOUND. 

A  MAN  in  the  neighbourhood  of  St.  Giles's  had  a  quarrel  with 
his  wife;  in  which  he  struck  her  over  the  head  with  a  mop-stick. 
The  blow  was  a  smart  one,  but  as  it  neither  fetched  blood,  nor 
brought  her  to  the  ground,  it  only  finished  the  dispute,  and  no 
farther  notice  was  taken  of  it.  The  woman  followed  her  busi- 
ness, which  was  that  of  crying  greens  about  the  streets,  and  lived 
(to  use  her  own  words)  sometimes  drunk,  sometimes  sober,  for  a 
week.  On  the  eighth  day  from  that  of  the  blow,  she  found  her- 
self so  ill,  that  she  applied  to  the  hospital  for  admission;  and  was 
taken  in  as  a  physician's  patient  for  a  fever.  The  doctor  wrote 
for  her;  and  the  day  after  this  (the  tenth  from  the  accident)  the 
sister  of  the  ward,  in  cutting  off  the  patient's  hair,  which  was  full 
of  vermin,  discovered  a  swelling,  which  she  desired  me  to  look 
at:  it  was  flattish,  about  the  breadth  of  the  palm  of  a  hand,  and 
lay  immediately  across  the  sagittal  suture.  The  woman  had  now 
a  hard  full  pulse,  a  hot  dry  skin,  a  black  tongue,  a  frequent  in- 
clination to  vomit,  great  thirst,  intense  pain  in  her  head,  and  got 
no  sleep.  From  these  symptoms  and  appearances,  and  from  the 
account  which  the  woman  now  first  gave  of  the  blow,  I  made  no 
hesitation  to  say,  such  blow  was  the  cause  of  all  her  symptoms. 


PROM  EXTERNAL  VIOLENCE.  75 

That  night  she  had  a  severe  rigor,  and  the  next  day,  the  eleventh, 
an  erysipelas  had  taken  possession  of  part  of  her  visage.  I  open- 
ed the  tumor,  and  finding  the  bone  bare,  cleared  away  the  scalp 
largely,  and  circularly.  I  then  applied  a  trephine  on  one  side  of 
the  suture  and  close  to  it,  and  found  the  dura  mater  altered  in  hs 
natural  colour,  and,  as  it  were,  smeared  over  with  matter.  She 
passed  the  succeeding  night  very  ill,  was  in  great  pain,  got  no 
sleep,  and  had  two  shiverings.  When  I  came  to  her  the  next 
day,  her  whole  visage  was  covered  with  an  erysipelas,  and  so 
swollen,  that  she  could  not  open  her  eyelids.  I  applied  the  tre- 
phine on  the  other  side  of  the  suture,  and  found  the  same  ap- 
pearance, viz.  matter  on  the  surface  of  the  membrane.  She  had 
within  the  last  two  days  been  let  blood  three  times,  and  had  con- 
stantly taken  such  medicines  as  the  physician  had  ordered  for  her, 
and  which  were  calculated  to  abate  her  fever,  and  keep  her  body 
open.  Her  symptoms  still  continued  without  abatement,  the 
wound  of  the  scalp  bore  as  bad  an  aspect  as  possible,  she  talked 
very  inconsistently,  got  not  a  wink  of  sleep,  and  called  perpetually 
for  drink.  As  the  quantity  of  bone  made  bare  by  the  removal  of 
the  scalp  gave  room  for  the  farther  application  of  the  instrument, 
I  made  a  third  perforation  near  to  the  first,  and  immediately  gave 
thereby  discharge  to  so  large  a  quantity  of  matter,  as  to  satisfy  me 
tlie  event  must  be  fatal. 

The  next  day  the  right  arm  and  leg  became  paralytic;  and  the 
day  following  that,  from  having  been  raving,  she  sunk  into  a  state 
of  perfect  insensibility,  had  a  short,  laborious  respiration,  a  small, 
interrupted,  faltering  pulse,  and  cold  extremities,  and  on  the  six- 
teenth day  from  that  of  the  accident  she  died. 

Upon  opening  the  head,  the  dura  mater  was  found  covered  with 
matter,  under  the  whole  internal  surface  of  both  the  parietal 
bones;  but  the  firm  adhesion  of  the  longitudinal  sinus  to  the  sagit- 
tal suture  had  prevented  all  communication  between  the  two  col- 
le<;tions  of  matter. 


INJURIES  OF  THE  HEAD, 


CASE  VIII. 


CONTUSION  WITH  W0UN1>. 


A  LUNATIC  threw  himself  from  a  vvindovv,  two  stories  high, 
and  in  his  fall  struck  his  head,  first  against  a  sign-iron  and  then 
against  a  slated  pent-house. 

He  was  taken  up  senseless,  with  three  wounds  on  his  head;  one 
just  above  the  right  temple,  and  two  on  the  top  of  his  head:  the 
wounds  were  but  small,  nor  was  the  pericranium  divided  in  any  of 
them.  He  remained  stupid  above  twelve  hours;  but  being  in  that 
space  of  time  let  blood  freely  twice,  he  recovered  his  senses,  but 
shewed  no  signs  of  a  right  understanding.  He  passed  two  days 
and  nights  in  the  utmost  disorder  and  disturbance.  He  was  con- 
fined in  a  strait  waistcoat,  and  kept  two  people  constantly  employ- 
ed in  holding  him:  at  last,  by  repeated  phlebotomy,  and  taking  a 
large  quantity  of  opium,  he  fell  asleep,  slept  near  twelve  hours,  and 
then  awoke  perfectly  tranquil,  and  perfectly  rational.  By  the 
sixth  day  from  that  of  the  fall,  his  wounds  were  in  perfect  good 
order,  and  seemed  to  heal  without  any  trouble;  the  man  was  in 
very  good  health  and  temper,  and  perfectly  rational  and  intelligent. 
He  would  have  been  permitted  by  his  friends  to  have  gone  out  a 
little  way  into  the  country;  but  lest  there  should  be  any  latent 
mischief,  I  advised  him  to  keep  quiet  a  little  longer,  and  to  live 
with  great  caution;  which  advice  was  followed.  On  the  tenth 
day  from  that  of  the  accident,  he  lost  his  appetite,  looked  dull 
and  languid,  refused  food  and  company,  complained  that  his  head 
ached,  and  said  that  he  had  not  slept.  So  little  time  had  passed 
since  he  had  been  disordered  in  his  mind,  that  from  his  aspect  and 
manner  I  suspected  a  return  of  his  lunacy.  I  let  him  blood  again, 
directed  that  he  might  be  kept  low,  and  desired  his  brother,  who 
was  an  apothecary,  to  give  him  an  opiate  at  going  to  bed.  The 
next  day,  the  eleventh,  he  said  that  his  head-ach  had  again  pre- 
vented him  from  sleeping  all  night,  and  that  he  felt  as  if  a  cord 
was  bound  tight  about  his  brain:  his  skin  was  too  hot,  his  pulse 
was  too  hard  and  too  frequent;  his  urine  small  in  quantity,  and 


FROM  EXTERNAL  VJOLENCK.  11 

high  coloured;  and  the  aspect  of  the  wounds  in  the  scalp  by  no 
means  so  favourable  as  they  had  hitherto  been:  one  of  them  looked 
more  spongy  and  pale  than  the  others.  I  examined  with  my  probe, 
and  found  the  scull  bare  for  some  space  under  it.  With  his  own 
and  brother's  consent,  I  removed  all  the  scalp  covering  the  bare 
cranium,  and  found  it  to  be  considerably  altered  from  a  natural 
colour.  I  bled  him  again,  and  desired  that  he  might  take  freely 
of  the  salt  of  wormwood  and  lemon-juice  until  the  next  day.  That 
night  he  had  a  smart  rigor,  and  the  next  morning,  finding  him 
worse  and  more  disturbed,  I  made  a  perforation  of  the  sCuU.  The 
.dura  mater  under  this  perforation  was  dull,  and  had  apparently 
matter  on  its  surface,  though  small  in  quantity.  He  was  dressed 
lightly;  and,  as  his  pulse  would  very  well  bear  it,  eight  ounces 
more  of  blood  were  drawn  off.  The  following  morning,  the  thir- 
teenth, he  had  a  still  more  severe  shivering,  his  pain  in  his  head 
was  greater,  his  fever  higher,  and  the  whole  sore  so  crude,  that  the 
lint  was  with  difficulty  removed  from  it.  I  applied  the  trephine 
again,  and  found  the  same  appearance,  viz.  a  dull  discoloured  dura 
mater,  and  a  small  quantity  of  matter.  That  evening  he  had  an- 
other rigor,  and  was  the  following  day  manifestly  worse.  Con- 
vinced, from  the  symptoms,  of  his  hazard,  and  firmly  believing 
that  matter  was  collected  in  such  manner  as  not  to  be  discharged 
by  the  two  openings  already  made,  I  ventured  to  make  a  third, 
and  that  a  large  one;  which  produced  an  immediate  and 
large  discharge  of  pus.  In  seven  or  eight  hours  I  saw  him  again, 
and  found  him  easier  and  more  tranquil.  He  had  slept  nearly  an 
hour,  and  his  pulse  did  not  feel  so  rapid,  nor  so  hard.  That  even- 
ing he  got  more  sleep,  and  the  following  morning  answered  every 
question  asked,  in  such  manner  as  to  convince  every  body  that  he 
was  certainly  better.  To  shorten  the  relation,  I  shall  only  add, 
that  the  discharge  continued  large  for  several  days,  and  then  gra- 
dually decreased:  all  his  symptoms  by  degrees  also  disappeared, 
and  hi  no  great  length  of  time,  by  proper  care,  he  got  very  well. 

When  this  patient  was  attacked  with  his  first  symptoms,  I  did 
not  suspect  the  true  cause.  His  want  of  sleep,  his  seeming  anxie- 
ty, his  taciturnity,  and  great  unwillingness  to  answer  any  ques- 
tion, seemed  to  me  to  bespeak  a  return  of  his  maniacal  disorder. 
Upon  this  supposition  I  gave  him  the  opiate,  hoping,  that  if  I 


"78  INJURIES  OF  THE  HEAD 

could  procure  sleep  he  might  be  better.  But  when  I  saw  the  al- 
tei-ed  appearance  of  the  wound,  and  found  that  the  pericranium 
had  quitted  its  adhesion  to  the  scuIJ,  I  was  no  longer  in  doubt, 
that  whatever  else  might  concur  to  disorder  him,  yet  all  his  com- 
plaints were  fairly  deducible  from  the  effects  of  his  fall.  And  I 
apprehend  he  owed  the  preservation  of  his  life  to  the  treatment 
he  underwent,  in  consequence  of  such  supposition. 


CASE  IX. 

CONTUSION   WITH  WOUNDS. 

A  WATCHMAN,  whosc  Stand  was  in  White-chapel,  got  into  a 
scuffle  with  some  drunken  sailors,  and  received  several  wounds 
and  blows  on  his  head;  from  some  of  which  he  lost  so  much  blood, 
that  he  was  the  next  day  brought  into  St.  Bartholomew's  hospital 
in  a  very  weak  low  state. 

Not  one  of  the  wounds,  which  were  five  in  number,  had  passed 
the  pericranium,  but  his  whole  head  was  very  much  swollen  and 
bruised.  He  was  in  other  respects  very  well;  that  is,  he  did  not 
complain  of  sickness,  nor  any  other  kind  of  pain  than  what  sore- 
ness the  bruises  necessarily  occasioned;  and  he  had  the  full  and 
perfect  use  of  his  senses.  As  he  had  already  sustained  great  loss 
of  blood,  and  was  more  than  sixty  years  old,  I  made  use  of  no  far- 
ther evacuation,  but  dressed  his  head  superficially,  and  directed 
that  he  should  be  kept  in  bed.  At  the  end  of  about  a  week,  the 
general  tumefaction  was  nearly  gone,  and  all  the  wounds  in  a 
healing  state;  the  man  transgressed  the  rules  of  the  hospital  by 
staying  out  all  night,  and  was  discharged.  On  the  fifteenth  day 
from  that  of  the  accident,  he  came  to  me  again,  complaining  of 
head-ach,  giddiness,  sickness,  failure  of  strength,  loss  of  appetite, 
and  want  of  sleep. 

All  the  wounds,  except  one,  were  perfectly  healed;  this  was  on 
the  upper  part  of  the  right  parietal  bone;  it  was  crude,  spongy, 
and  the  exuberant  flesh  of  such  colour  and  consistence,  as  inclined 
me  (considering  at  the  same  time  his  general  symptoms)  to  sus- 
pect mischief  underneath  it.     I  took  him  into  the  house  again, 


FROM  EXTERNAL  VIOLENCE.  79 

«nd  immediately  removed  a  circular  portion  of  the  scalp,  includ- 
ing the  wound,  and  found  both  pericranium  and  scull  in  the  state 
I  suspected;  that  is,  the  former  altered  and  detached,  and  conse- 
quently the  latter  bare.  Neither  the  age,  habit,  nor  state  of  the 
man,  seemed  to  be  capable  of  bearing  free  evacuation,  nor  did  I 
in  my  own  opinion  believe  that  there  was  time  for  the  experi- 
ment. I  therefore  perforated  the  middle  of  the  bare  part  of  the 
bone,  and  found  a  sufficient  warrant  for  having  so  done;  that  is, 
a  small  quantity  of  maUer  on  the  surface  of  the  dura  mater.  His 
head  was  dressed  lightly,  a  little  blood  was  drawn  from  one  of  his 
arms,  and  a  clyster  thrown  up  to  procure  a  stool.  The  following 
night  he  passed  ill:  had  a  slight  shivering,  got  little  or  no  sleep, 
and  complained  very  much  of  pain  in  his  head;  the  bare  mem- 
brane looked  very  crude,  discharged  a  thin  gleet,  and  pressed 
hard  against  the  edges  of  the  bone.  The  next  day,  his  pulse  be- 
ing considerably  risen,  he  was  let  blood  again:  that  afternoon  he 
had  another  rigor,  and  his  pain  as  well  as  fever  became  more  in- 
tense. 

On  the  eighteenth  day,  finding  him  in  every  respect  worse,  I 
made  another  perforation  just  below  the  former,  and  gave  thereby 
a  discharge  to  a  larger  quantity  of  matter,  which  the  close  pres- 
sure of  the  dura  mater  against  the  edges  of  the  perforation  had 
hitherto  confined.  On  the  twentieth,  he  was  indeed  rather  easier, 
but  his  fever  was  very  high,  and  both  the  dura  mater  and  sore  in 
the  scalp  looked  very  ill;  wherefore  suspecting  more  matter,  and 
being  satisfied  the  man  had  no  other  chance  for  life,  I  made  a 
third  perforation  close  by  the  second.  This  procured  so  large  a 
discharge  of  pus,  that  I  was  very  apprehensive  that  the  extent  of 
the  mischief  was  too  great  for  the  assistance  of  art  to  prove  effec- 
tual in:  however,  I  was  happily  disa.ppointed:  for  in  a  very  few 
days  more,  all  his  bad  symptoms  gradually  left  him,  and  the  man 
got  perfectly  well. 

From  considering  all  the  circumstances  of  this  case,  I  am  satis- 
fied, that  had  not  the  cranium  been  perforated  at  all,  the  man 
must  have  died,  from  the  collection  and  confinement  of  matter: 
and  I  am  also  as  much  convinced,  that  the  two  former  perfora- 
tions would  have  proved  insufficient  for  the  purpose,  and  that  the 
man  owed  his  preservation  to  the  large  removal  of  bone. 


80  LNJUKIKS  ur  THE  HEAD 

This  is  a  point  of  practice,  which  has  by  no  means  been  suffi- 
ciently attended  to  by  practitioners,  nor  sufficiently  inculcated  by 
the  writers  of  our  country  at  least.  Many,  who  see  and  are  con- 
vinced of  the  justness  and  propriety  of  it,  want  authority  to  vindi- 
cate them  in  proposing  or  executing  it;  and  some  part  of  the  dis- 
grace which  has  been  cast  on  the  operation  of  the  trepan  has 
arisen  from  this  cause.  Practitioners  have  in  general  been  afraid  to 
make  more  than  one  opening,  and  that  generally  a  small  one.  If 
the  inflammation  be  of  any  extent,  or  the  quantity  of  matter  at  all 
considerable,  this  one  small  opening  must  prove  insufficient,  either 
for  the  relief  of  the  tense  inflamed  membrane,  or  for  the  evacua- 
tion of  the  fluid;  and  the  only  probable  chance  which  the  patient 
can  have,  must  be  from  the  removal  of  a  large  portion  of  bone; 
and  this  equally  in  the  case  of  exiravasation  of  blood  or  serum,  as 
in  that  of  abscess. 


CASE  X. 

CONTUSION  JOINED  WITH  EXTRAVASATION. 

A  FIREMAN,  who  was  at  work  on  the  top  of  a  house,  fell  in  with 
the  roof  of  it ;  he  was  taken  out  senseless,  and  brought  in  that 
state  to  the  hospital. 

He  had  on  diiferent  parts  of  his  body  several  wounds  and 
bruises,  but  none  of  them  seemed  to  be  of  any  great  consequence. 
On  his  head  were  four,  one  of  some  size,  on  the  upper  part  of  the 
frontal  bone  near  to  the  coronal  suture,  two  on  the  left  parietal, 
one  on  the  right  side  of  his  head,  just  above  his  ear,  and  a  small 
bruise  on  the  upper  part  of  the  os  occipitis.  Of  all  these  wounds, 
the  pericranium  was  divided  in  one  only,  viz.  that  near  the  coro- 
nal suture. 

His  wounds  were  dressed,  he  was  largely  bled,  a  clyster  was 
thrown  up,  and  a  purging  mixture  was  ordered  to  be  given 
cochleatim,  until  he  should  have  a  discharge  per  anum.  The 
next  day  he  was  in  the  same  slate,  perfectly  senseless,  had  the 
apoplectic  sterior,  a  full  labouring  interrupted  pulse,  and  some 
difficulty  of  respiration.     He  had  four  or  five  large  stools,  where- 


KROM  EXTERNAL  VIOLENCE.  81 

fore  his  mixture  was  discontinued,  but  sixteen  ounces  more  of 
blood  were  drawn  from  one  of  the  jugular  veins;  which  evacuation 
was  repeated  again  in  the  evening  of  the  same  day,  to  the  quanti- 
ty of  eight  more.  On  the  third  day,  being  still  perfectly  stupid, 
discharging  both  urine  and  faeces  involuntarily,  and  having  still  a 
full  labouring  pulse,  both  the  temporal  arteries  were  opened,  and 
fourteen  ounces  drawn  from  thence.  On  the  fourth,  finding  no 
alterjition,  and  being  satisfied  that  the  man's  state  could  hardly  be 
made  worse,  I  determined  to  perforate  the  cranium,  and  ac- 
cordingly set  a  large  trephine  on  the  upper  part  of  the  frontal  bone, 
where  the  pericranium  had  been  divided.  The  dura  mater  was 
found  to  be  thinly  covered  with  grumous  blood,  some  of  which  I 
removed,  and  thereby  made  way  for  the  discharge  of  more.  The 
next  day  (ihe  fifth),  finding  that  what  discharge  had  been  made, 
during  the  night,  was  bloody,  and  that  the  man  was  in  no  respect 
altered  for  the  better,  I  thought  I  had  sufficient  authority  for  re- 
peating the  operation,  which  I  accordingly  did,  close  by  and  be- 
low the  former;  and  as  the  blow,  by  which  the  wound  had  been 
inflicted,  seemed  to  have  been  almost  exactly  on  the  top  of  his 
bead,  I  made  a  third  opening  in  the  parietal  bone,  close  to  the 
suture.  The  appearance  under  all  was  the  same  as  under  the 
first,  viz.  a  thin  layer  of  grumous,  or  rather  coagulated  blood. 

Next  day  (the  sixUi),  toward  evening,  the  man  opened  his  eyes; 
and  on  the  seventh  in  the  morning  he  spake.  The  discharge  of 
blood  continued  for  several  days,  and  at  the  end  of  about  a  week 
from  this  time  ceased;  the  dura  mater  and  the  wounded  scalp 
wearing  as  good  an  aspect  as  could  be  wished,  and  the  patient  be- 
ing easy  and  rational. 

On  the  eighteenth  day,  he  complained  of  pain  all  over  his 
head;  was  sick,  reached  to  vomit,  and  said  that  he  was  faint 
and  chilly.  On  the  nineteenth,  his  face  was  flushed,  his  skia 
hot,  his  pulse  quick  and  hard.  He  was  let  blood,  and  ordered  to 
have  a  clyster,  and  to  take  some  medicines  of  a  febrifuge  kind.  A 
day  or  two  more  passed  in  this  manner,  his  fever  not  violent,  but 
rather  increasing  than  remitting;  his  pain,  though  not  acute,  yet 
such  as  to  deprive  him  of  his  sleep;  little  rigors  occurring  irregu- 
larly, no  perspiration,  and  an  excessive  'anguor.  At  l^ist,  on  the 
twenty-first  day,  on  the  upper  part  of  the  os  occipitis,  on  the 

ve>L.  I.  L 


82  INJURIES  OF  THE  HEAD 

right  sid€  where  there  had  been  a  small  bruise,  a  tumor  arose,  so 
characterised,  as  to  satisfy  me  that  the  cause  of  the  late  alteration 
of  circumstances  lay  underneath  it:  it  did  not  rise  to  any  height, 
and  contained  a  small  quantity  of  sanies,  but  covered  a  portion 
of  bone  which  the  pericranium  had  quitted.  I  removed  the  scalp, 
and  would  have  set  on  a  trephine,  but  the  man  obstinately  refused 
to  submit  to  it. 

On  the  twenty-fifth  day,  he  lost  the  use  of  his  left  leg  and  arm, 
and  was  at  the  same  time  much  convulsed  in  his  right;  which 
paralysis  and  spasm  continued  until  the  twenty-seventh,  and  on 
the  twenty-eighth  he  died. 

Upon  examining  his  head,  a  collection  of  matter  was  found 
under  the  bare  part  of  the  occipital  bone;  the  dura  mater  under 
this  matter  was  sloughy  and  putrid,  and  about  a  desert  spoonful  of 
matter  lay  between  the  meninges,  just  under  the  altered  part  of 
the  dura  mater.  In  the  part  where  the  bloody  extravasation  had 
been,  every  thing  was  perfectly  fair  and  free  from  disease. 

In  this  case,  there  seems  to  have  been  as  clear  a  distinction  be- 
tween the  bloody  extravasation,  with  its  effects,  and  the  inflamma- 
tory state  of  the  dura  mater,  with  its  consequences,  as  can  be  de- 
sired. All  the  first  symptoms  were  such  as  were  caused  by  mere 
pressure  of  the  extravasated  blood;  an  obliteration  of  every  sensi- 
ble faculty,  attended  with  the  principal  symptoms  of  an  interrupt- 
ed circulation.  Perforation  of  the  scull,  where  this  extravasation 
had  been  made,  did,  by  giving  discharge  to  the  blood,  happily  re- 
move these,  and  the  man  was  getting  well  apace,  until  the  ills  aris- 
ing from  another  cause,  viz.  the  inflammatory  secession  of  the 
dura  mater  in  consequence  of  contusion,  and  that  in  another  place, 
began  to  appear;  they  indeed  made  their  attack  rather  late,  nor 
did  they  rise  so  high  as  they  most  frequently  do;  but  then  it  must 
b€  considered  what  discipline  the  poor  man  had  undergone,  and 
what  evacuation  had  been  made.  Notwithstanding  which,  they 
bore  their  true,  genuine,  febrile,  inflammatory  character,  and  pro- 
duced their  most  frequent  event.  What  perforation  of  the  os 
occipitale  might  have  done,  I  cannot  say;  I  fear  but  little,  as  the 
matter  was  not  only  upon,  but  underneath  the  dura  mater,  and 
that  too  diseased. 


FROM  EXTERNAL  VIOLENCE,  83 


CASE  XL 


CONTUSION  WITH  WOUND. 


A  DRAYMAN,  drunk,  and  sleeping,  fell  from  his  dray,  and  his 
liead  was  so  squeezed  between  the  wheel  and  a  post,  that  a  con- 
siderable portion  of  the  scalp,  together  with  the  pericranium,  wag 
forced  off  from  each  parietal  bone. 

He  was  brought  to  the  hospital  senseless:  he  was  largely  let 
blood,  and  the  separated  scalp  being  so  bruised  and  mangled  as  to 
afford  no  probability  of  re-union,  it  was  removed,  and  the  bone 
dressed  with  dry  lint.  The  next  day  the  man  was  so  well,  and  so 
perfectly  master  of  what  sense  he  had,  that  I  was  inclined  to  be- 
lieve, that  a  great  deal  of  the  last  night's  appearance  was  owing 
principally  to  liquor. 

In  ten  days  time,  the  edges  of  the  torn  scalp  were  digested,  and 
bore  all  the  appearance  of  sores  in  a  healthy  man.  One  of  the 
parietal  bones  seemed  disposed  to  granulate  without  any  exfoliation, 
the  other  looked  as  if  it  would  throw  off  a  scale. 

On  the  thirteenth  day  he  was  so  well,  that  having  a  large  family 
to  work  for,  he  desired  to  be  discharged  from  the  hospital,  and  to 
be  made  an  out-patient;  but  his  sores  were  still  so  large,  and  I  had 
so  often  been  deceived  by  the  fallacious  appearance  of  such  cases, 
that  I  persuaded  him  to  stay  another  week. 

On  the  sixteenth  day  he  complained  much  of  head-ach,  and 
said,  that  he  was  sick  and  chilly;  on  the  seventeenth,  the  florid, 
granulated  appearance,  and  laudable  matter  of  the  sores,  were  ex- 
changed for  a  tawny,  glassy  surface,  and  a  plentiful  thin  gleet.  I 
bled  him  freely,  and  bid  him  keep  in  bed.  On  the  same  day,  to- 
ward evening,  he  had  a  shivering,  and,  the  day  following,  twa 
more;  that  parietal  bone  (the  left)  which  had  hitherto  looked  as  if 
it  would  be  covered  by  a  granulation,  without  exfoliating,  now 
wore  so  diseased  an  aspect,  that  I  fain  would  have  set  a  trephine 
on  it  immediately,  but  the  man  would  not  permit  me.  Every 
other  means  were  used,  but  to  no  purpose.  The  sore  on  the  right 
side  of  the  head  continued  to  look  well,  but  the  scalp  quitted  its 


81  INJURIES  OF  THE  HEAD 

adhesion  to  almost  the  whole  left  parietal  bone,  which  bone  looked 
very  unlike  to  a  healthy  one. 

On  the  twenty-third  day  from  that  of  the  accident,  he  died, 
having  been  paralytic  in  his  right  leg  and  arm  from  the  twenty- 
first. 

The  appearance  of  the  two  sores,  as  well  as  of  the  two  bones, 
Avere  so  different,  that  I  had  curiosity  to  see  the  state  of  the  parts 
underneath  each.  On  the  right  side,  the  dura  mater  was  in  a  na- 
tural, sound,  adherent  state.  On  the  left,  it  was  separated  from 
almost  the  whole  bone,  and  covered  plentifully  by  matter,  and  was, 
for  about  the  breadth  of  a  half-crown,  sloughy;  under  the  slough 
the  pia  mater  was  diseased  also,  and  matter  was  also  formed  ort 
the  surface  of  the  brain. 


CASE  Xli. 

The  following  case  was  brought  into  St.  Bartholomew's  hospital^ 
while  I  VMS  confined  to  my  house  by  sickness.  The  account, 
therefore,  of  the  patient,  while  living,  is  as  taken  by  Mr.  Earle, 
(the  present  Editor) ;  and  that  of  the  appearance  after  death,  is 
in  the  words  of  the  late  ingenious  Mr.  Partridge,  who  assisted 
Mr.  Earle  in  the  examination  of  the  body. 

On  the  tenth  of  February,  1765,  John  Biggs,  a  lad  about  thir- 
teen years  old,  was  driving  a  horse  round  a  grinding-mill;  the 
horse  not  being  used  to  the  work,  ran  round  very  fast;  the  boy 
fell,  and  received  such  a  blow  from  some  part  of  the  frame  ic 
which  the  horse  worked,  that  he  lay,  deprived  of  sense,  for  some 
time,  that  is,  until  somebody  came  in  to  inquire  why  the  mill 
went  so  rapid.  He  had  a  small  wound  on  the  right  side  of  his 
head,  and  no  other  apparent  mark  of  injury.  In  a  few  hours,  by 
the  assistance  of  phlebotomy,  he  seemed  to  be  very  well  again. 
His  wound  was  dressed  by  the  family  apothecary  for  a  week,  dur- 
ing which  time  he  did  not  seem  to  have  any  other  complaint,  ex- 
cept noiv  and  then  having  a  slight  head-ach.  The  wound  not 
Jiealing  kindly,  the  boy,  being  a  country  boy,  hired  only  for  the 


PROM  EXTERNAL  VIOLENCE.  85 

purpose  of  driving  the  mill-horse,  and  the  people  with  whom  he 
lived  being  tired  of  keeping  him  unemployed,  he  was  brought  to 
the  hospital.  The  wound  was  not  large,  and  although  he  did 
pot  seem  to  have  any  other  complaint,  was  nearly  three  weeks  in 
healing. 

On  the  eighth  of  March,  he  was  seized  with  a  fever,  beginning 
with  a  kind  of  cold  fit.  On  the  tenth  he  was  much  disordered, 
complained  of  acute  pain  in  his  head;  and  his  wound,  which  had 
been  healed,  broke  out  again,  the  pericranium  separating  from  the 
bone;  on  the  twelfth,  he  became  senseless  to  all  ouUvard  objects, 
was  convulsed  in  all  his  limbs,  and  jaw-locked.  On  this  day  Mr. 
Crane  trepanned  him  on  the  upper,  fore  and  right  side  of  the 
frontal  bone.  On  the  surface  of  the  dura  mater  was  found  a  con- 
siderable quantity  of  good  matter:  on  the  next  morning  he  died. 

The  dura  mater  was  detached  from  the  cranium  for  about  an 
inch,  all  round  the  perforation  of  the  bone;  what  matter  had  been 
formed  on  its  surface  had  been  discharged  by  the  operation,  and 
little  or  none  lodged;  the  pia  mater  and  brain  sound  in  this  part. 
At  about  two  inches  distance  from  the  original  wound,  higher  up, 
and  nearer  both  to  the  coronal  a»d  sagittal  sutures,  was  a  small 
tumor  about  the  size  of  a  split  garden  bean;  within  this  was  a  very 
little  discoloured  matter,  and  under  it  the  bone  was  bare.  The 
dura  mater  corresponding  with  this  tumor  was  detached,  black, 
and  sloughy,  and  a  considerable  quantity  of  matter  lay  under  this 
sloughy  part,  communicating  with  an  abscess  formed  between 
the  two  hemispheres  of  the  brain,  on  the  right  side  of  the  falciform 
process. 


SECT.  III. 


SEPARATIOK,  OR  DESTRUCTION  OF  BOTH  TABLES  OF  THE  SCULL, 
FROM  CONTUSION. 

The  separation  of  a  portion  of  the  cranium,  consisting  of  both 
tables,  or  of  the  whole  thickness,  happens  not  unfrequently  in  old 
or  neglected  venereal  disorders.   The  disease,  which  in  these  cases 


86  INJURIES  OF  THE  HEAD 

has  its  seat  in  the  diploe,  often  spoils  the  whole  substance  of  the 
bone,  and  produces  a  separation  or  exfoliation  of  its  whole  thick- 
ness: the  dura  mater  being  always  found,  in  such  case,  to  be  co- 
vered only  by  an  incarnation  generated  from  its  surface. 

This  kind  of  caries  is  sometimes  of  large  extent,  in  one  piece, 
but  more  frequently  it  is  of  smaller  size,"  and  affects  diiferent 
parts  of  the  same  scull.  The  separated  piece  is  generally  quite 
carious,  and  appears  as  if  it  had  been  worm-eaten,  (what  the 
French  call  vermoM/owe).  The  surface  of  the  bone  so  diseased  is 
seldom  much  elevated,  though  generally  somewhat;  neither  has  it 
often  the  circumscribed  form  and  appearance  of  a  true  node,  as  it 
is  called;  though  now  and  then  it  has. 

The  scalp,  which  covers  a  bone  in  this  state,  is  most  frequently 
diseased  also;  sometimes  with  one  large,  ill-conditioned  sore;  but 
more  often  with  a  number  of  crude,  foul,  painful,  serpiginous  ul- 
cers; through  most  of  which  a  probe  will  discover  a  rough,  bare 
bone;  and  from  which  is  constantly  discharged  a  greasy,  stinking 
sanies.  This  complaint  is  generally  accompanied  by  a  nocturnal 
head-ach,  pocky  spots,  and  pains  about  the  breast  and  shoulders; 
and  is  almost  always  preceded  by  the  former,  though  very  fre- 
quently that  symptom  ceases,  either  during  the  mercurial  courses, 
instituted  for  that  purpose,  or  when  the  pericranium  covering  the 
diseased  part  becomes  foul  and  sloughy. 

The  proportion  of  extent  of  surface,  which  one  table  of  these 
diseased  parts  of  the  cranium  bears  to  the  diseased  part  of  the  other 
table,  is  very  uncertain,  and  often  very  unequal.  Sometimes  the 
alteration  of  the  outer  table  is  much  more  extensive  than  that  of 
the  inner;  in  which  case,  when  the  separation  is  made,  the  de- 
tached piece  comes  away  very  easily,  and  the  uncovered  part  of 
the  dura  mater  is  small,  compared  to  the  size  of  the  external  sore; 
but  sometimes,  on  the  contrary,  the  disease  occupies  a  more  con- 
siderable extent  of  the  inner  table  than  of  the  outer,  and  thereby 
renders  the  case  more  difficult,  and  the  cure  more  tedious. 

A  mercurial  course  begun  even  before  the  scalp  covering  the 
diseased  parts  shall  have  been  ulcerated,  though  it  be  often  suffici- 

"  I  iiave  seen,  in  one  case,  nearly  tlip  whole  os  frontale  cast  off;  and,  in 
another,  the  whole  left  parietal  bone. 


FROM  EXTERNAL  VIOLENCE.  87 

ent  fully  and  perfectly  to  eradicate  the  lues  from  the  habit,  will 
neither  prevent  nor  cure  this  local  malady;  which  will  therefore 
often  remain,  after  such  cause  of  it  has  been  really  and  totally 
removed:  the  bone  is  thoroughly  spoiled  (at  least  in  the  parts  af- 
fected); and  although  the  disease,  considered  abstractedly,  be 
cured,  yet  the  texture  of  these  harder  parts  necessarily  requires 
more  time  to  cast  off  what  is  unsound,  and  to  put  on  a  healthy  ap- 
pearance, than  the  softer  do;  the  local  distemper  will  remain  a 
long  lime  after.  An  inattention  to,  or  a  misunderstanding  of  this 
circumstance,  has  been  the  cause  why  many  people  have  been 
harassed,  and  even  destroyed  with  unnecessary  mercurial  processes, 
when  the  complaint  has  been  truly  local,  which  it  frequently  is 
after  proper  previous  mercurial  treatment.  Such  medicines  will 
be  found  to  be  so  far  from  hastening  the  remoA'^al,  that,  by  spoiling 
the  constitution,  relaxing  the  solids,  impoverishing  and  dissolving 
the  fluids,  and  weakening  the  vis  vitae,  they  prevent  nature  from 
executing  her  own  purpose,  and  really  protract  and  retard  that 
effect  which  they  are  used  (though  injudiciously)  with  design  to 
expedite.  Mercury  is  undoubtedly  a  specific  for  the  venereal  dis- 
ease, but  it  is  itself  a  poison.  It  will  also  cure  some  other  diseases; 
but  its  effects  on  the  human  frame  are  neither  light  nor  superficial. 
It  becomes  beneficial  or  prejudicial,  according  to  the  manner  in 
which  it  is  applied;  and  when  it  ceases  to  do  good,  it  will  most 
certainly  do  harm.  This,  though  a  very  flagrant  instance  of  it,  is 
not  the  only  one  which  might  be  produced;  the  same  observation 
might  be  made  on  the  maladies  proceeding  from  a  diseased  pros- 
tate and  urethra,  producing  indurations,  and  fistulas  in  perineo,  in 
which  the  persistance  in  the  use  of  mercurials,  after  the  producing 
lues  has  been  cured,  has  cost  many  a  man  his  life,  by  aggravat- 
ing and  continuing  that  symptomatic  hectic  fever  (the  necessary 
consequence  of  pain  and  irritation)  which  it  should  be  the  whole 
business  of  art  to  calm  and  attemperate.  In  all  these  cases,  a 
strong  decoction  of  sarsaparilla  with  milk  for  the  common  drink,, 
a  soft  nutritive  diet,  a  clear  air,  and  the  free  use  of  the  Peruvian 
bark,  will  be  found  to  be  more  conducive  to  the  patient's  reco- 
very, than  any  continued  use  qf  mercury.     By  the  former  he  will 


88  INJURIES  OP  THE  HEAfi 

be  restored  and  strengthened,  by  the  latter  he  will  be  irritated, 
wasted,  and  destroyed." 

*  Mr.  Potl's  remarks  on  the  abuse  of  mercury  are  extremely  valuable,  and 
deserve  every  attention.  Much  mischief  has  certainly  been  ciiused  by  continu- 
ing to  give  mercury  after  tlie  venereal  virus  has  been  subdued.  Mr.  Pott  lias 
in  this  place  somewhat  deviated  from  his  subject  of  injuries  of  the  head  from 
external  violence  ;  but  it  was  principally  to  shew  the  similitude  between  some 
exfoliations  which  are  caused  by  thejvenereal  virus,  and  others  which  are  some- 
times the  efl'ecl  of  contusion.  That  large  exfoliations  do  often  happen  in 
bones  which  have  been  affected  with  venereal  virus,  is  very  certain,  though, 
■without  question,  they  are  infinitely  less  frequent  than  formerly,  the  disease 
being  understood,  and  more  attention  being  paid  to  it  in  its  earlier  stages.  It  i$ 
now,  even  in  hospitals  and  among  the  lowest  order  of  persons,  very  rare  to 
see  a  carious  scull.  However,  what  has  been,  again  may  be.  I  have  certainly 
seen,  as  Mr.  Pott  observes,  exfoliations  almost  to  the  extent  of  the  frontal 
or  parietal  bones;  but,  by  judicious  management,  1  think  this  may  some- 
times be  avoided.  Exfoliation  of  bones  cannot  take  place,  most  particularly 
from  the  cranium,  without  causing  great  deformity  :  it  should  therefore  by 
all  possible  means  be  prevented.  Bones  being  uncovered,  and  exposed  to 
the  air,  is  the  great  cause  of  exfoliation  ;  and  this  it  is  the  duty  of  surgeons  as 
much  as  possible  to  avoid.  What  I  would  wish  to  Inculcate  is,  that  though 
through  an  opening  in  the  scalp  the  probe  discovers  a  bare  bone  with  a  rough 
surface,  it  should  by  no  means  be  uncovered,  as  I  believe  has  not  infre- 
quently been  practised  ;  and  the  admission  of  air  through  the  small  opening 
should  be  as  much  as  possible  prevented ;  or  where  there  are  several  open- 
ings leading  down  to  the  diseased  bone,  the  intermediate  skin  should  be 
carefully  preserved.  If  there  be  reason  for  suspicion  that  there  still  remains 
some  venereal  virus,  every  means  which  skill,  assisted  by  mercury,  can  em- 
ploy, should  be  used  to  stop  the  activity  of,  and  eradicate  the  poison.  When 
that  is  done,  provided  we  do  not  irritate  by  repeated  examinations,  or  the 
introduction  of  any  foreign  bod\',  the  diseased  bone  will  often  lie  quiet,  and 
any  further  destruction  or  deformity  will  be  avoided. 

As  this  observation  appears  to  me  important,  I  shall  endeavour  to  illus- 
trate it  by  relating  a  case  which  occurred  several  years  paSt.  I  Was  sent 
foi',  to  see  an  unmarried  lady  in  a  most  respectable  family,  who  had  a  sore 
on  her  forehead  a  little  above  the  left  eye-brow.  On  examination  with  a 
a  probe,  I  found  the  bone  bare ;  and  on  insinuating  it  further,  it  made  its 
way  over  the  whole  surHice  of  the  os  frontis,  which  was  separated  from  the 
scalp,  and  very  rough.  The  skin  covering  it  was  smooth,  even,  and  of  a 
liealthy  natural  appearance.  There  was  no  other  opening  or  communication 
with  the  bone,  except  that  just  mentioned :  there  were  some  other  tu- 
mors or  risings  on  other  parts  of  the  head.  Considering  all  these  appearances, 
which  were  accompanied  with  great  and  frequent  pain  in  the  head,  I 
made  no  doubt  of  its  arising  from  venereal  poison  in  the  habit.  My  opinion 
gave  great  olfence,  and  I  was  informed  that  the  lady,  v^hose  purity  I  had  so 
boldly  arraigned,  had  been  twelve  months  under  the  care  of  the  late  Dr.  F., 


FROM  EXTERNAL  VIOLENCE.  89 

The  same  kind  of  exfoliation  or  separation  of  both  tables  of 
the  cranium,  is  sometimes  the  consequence  of  mere  external  vio- 
lences 

The  four  following  examples,  which  have  fallen  within  my  own 
knowledge,  I  shall  relate  without  any  comment. 


CASE  XIII. 

A  gentleman's  coachman  was  thrown  from  his  box,  on  the 
road  between  London  and  Richmond,  and  received  a  wound  in 
his  forehead,  which  divided  the  pericranium,  and  denuded  the 
bone  about  an  inch  above  the  sinus.     The  man  received  no  other 

who,  had  there  been  any  grounds  for  my  suspicion,  must  have  discovered  it. 
However,  as  it  was  not  the  first  time  I  had  witnessed  the  Doctor's  total  igno- 
rance of  this  disease,  though  in  other  respects  acknowledged  by  the  world 
an  excellent  physician,  and  as  I  was  well  acquainted  with  the  various  forms 
and  appearances  the  venereal  proteus  can  assume,  I  would  not  give  up  my 
opinion;  though  at  the  same  time  I  affirmed  that  the  disease  might  be  inno- 
cently caught,  and  mentioned  some  cases  to  prove  this  assertion.  I  was  how- 
ever informed  that  my  future  attendance  would  be  dispensed  with.  About  a 
week  after,  I  was  desired  to  meet  Dr.  F.  and  two  other  physicians,  one  of 
whom  was  the  late  Sir  Richard  Jebb,  who,  on  seeing  the  case,  immediately 
pronounced  it  venereal. 

I  was  now  intreated  to  take  care  of  it,  and  by  the  usual  means  cured  the 
disease.  The  pains  in  the  head  ceased,  the  small  tumors  subsided,  and  no 
exfoliation  took  place  except  at  the  wound,  the  rest  of  the  forehead  remain- 
ing perfectly  firm,  and  the  skin  covering  it  without  further  opening  or  ul- 
ceration. 

The  disease  was  afterward  traced  from  a  woman  with  whom  the  lady  had 
slept,  and  who  had  a  venereal  ulcer,  which  had  probably  been  in  contact 
with  this  unfortunate  person  in  a  part,  from  which  the  cuticle  had  been  by 
some  accident  abraded.        E. 

y  Morgagni  deduces  this  from  mischief  done  to  the  vessels  of  the  diploe. 
**  Antequam  de  calvaria:  ictibus  verba  facere  desinamus,  illud  non  est  prse- 
"  tereundum,  utraque  ejus  tabula  prorsus  illsesa,  illsesisque  subjectarum  me- 
"  ningum  vasis,  accidere  aliquando  ab  ictu  valido  obtusi  corporis,  ut  vast  ula, 
"  quae  inter  tabulas  meduUse  subserviunt,  rumpantur,  et  sanguinem  fundantj 
"tqui  procedente  tempore  corruptus,  eoque  acrior  factus,  quod  succos  me- 
"  dullosus  admisceatur,  qui  tum  mora  et  calore,  in  pessimam  degeneret  ran- 
"  cedinem,  interiorem  tabulam  carie  afliciat;  hominique,  jam  ictu  obliio,  et 
"  nihil  ejusmodi  timenti,  intro  defiuens,  meninges  vitiet  necenique  afferat." 

De  Sedibus  et  Causis,  &c. 

VOL.  I.  M 


90  INJURIES  or  THE  HEAD 

harm  in  the  fall;  the  lips  of  the  wound  were  brought  together  by 
suture,  and  he  drove  home. 

Tiie  next  day  his  master,  who  was  a  governor  of  St.  Bartholo- 
mew's, and  a  timorous  man,  sent  the  patient  into  that  house.  As 
he  seemed  perfectly  well,  and  the  wound  looked  as  if  it  would 
unite  without  any  trouble,  I  dressed  him  only  with  a  superficial 
pledget.  This  did  not  succeed,  and  the  edges,  instead  of  uniting, 
became  spongy.  I  therefore  ordered  him  to  be  dressed  with  a 
little  dry  lint,  thinking  that  the  bare  bone  would  soon  throw  off  a 
small  scale,  and  finish  the  matter.  At  the  end  of  three  weeks 
every  thing  was  exactly  in  the  same  state;  the  bone  bare,  and  not 
likely  to  exfoliate,  and  the  edges  spongy.  Being  in  perfect  health, 
the  man  was  tired  of  the  confinement  of  the  hospital,  and  was 
permitted  to  go  home,  taking  dressings  with  him. 

At  the  end  of  two  months  from  the  date  of  the  fall,  he  returned 
to  the  hospital  again,  and  desired  me  to  look  at  his  sore;  which 
was  not  only  not  healed,  but  discharged  much  too  large  a  quanti- 
ty of  matter.  The  opening  was  about  the  size  of  a  silver  tliree- 
pence,  round,  soft,  and  spongy:  upon  feeling  with  a  probe,  I 
thought  that  the  bone  receded  too  much  for  a  mere  loose  exfolia- 
tion, and  as  the  bone  receded,  the  discharge  of  matter  increased. 
Upon  repeated  trials,  I  was  thoroughly  satisfied  that  both  these 
circumstances  were  true,  and  also  that  the  loose  piece  was  much 
too  large  to  be  extracted  from  the  present  opening. 

I  considered,  that  the  removal  of  a  circular  piece  of  skin  would 
leave  a  scar,  which  would  not  only  be  a  great  deformity,  but  a 
deformity  which  would  be  liable  to  misconstructions;  and  as  there 
were  no  bad  symptoms  to  be  obviated,  nor  any  thing  to  be  done, 
but  merely  to  remove  the  loose  portion  of  bone,  I  made  a  longi- 
tudinal incision,  sufficient  for  its  extraction,  and  laying  hold  of  it 
with  a  pair  of  forceps,  brought  it  away.  It  was  the  whole  thick- 
ness of  the  cranium,  in  every  part  firm,  hard,  and  perfectly  white; 
and  it  left  the  dura  mater  covered  by  a  florid  healthy  incarnation. 
I  laid  the  divided  scalp  down  upon  the  membrane,  without  any 
intervening  dressing,  and  the  sore  healed  in  a  few  days. 


FROM  EXTERNAL  VIOLENCE.  91 


CASE  XIV. 


An  elderly  woman  riding  in  a  hackney  landau,  by  a  sudden 
jolt  struck  her  head  with  great  violence  against  an  iron  hook  at 
the  top  of  it,  put  there  to  hold  the  two  parts  of  the  roof  together. 
The  blow  gave  her  exquisite  pain  for  the  instant,  but  that  soon 
ceased;  and  as  it  caused  neither  wound  nor  tumefaction,  she  took 
no  further  notice  of  it.  At  the  end  of  near  two  months,  she  was 
seized  with  a  violent  pain  in  her  head;  so  violent,  that  for  several 
nights  she  was  obliged  to  have  recourse  to  laudanum,  in  order  to 
obtain  a  little  broken  rest. 

In  about  a  week  her  pain  went  off,  and  a  tumor  arose,  just 
where  she  had  been  stricken;  that  is,  just  in  the  middle  of  the 
sagittal  suture. 

Mr.  Brown,  of  Little  Britain,  had  the  care  of  her:  with  him  I 
saw  her;  we  opened  the  tumor,  and  discharged  a  considerable 
quantity  of  discoloured  and  very  offensive  matter.  I  passed  my 
finger  into  the  opening,  and  to  my  great  astonishment  found  it 
touched  the  dura  mater.  We  removed  a  circular  piece  of  the 
scalp,  and  found  the  two  ossa  parietalia  bare,  and  carious  for  a 
considerable  extent  on  each  side  of  the  suture;  and  in  the  middle 
of  this  carious  piece,  just  in  the  track  of  the  suture,  a  hole  large 
enough  to  admit  easily  any  man's  finger,  without  touching  the 
edges  of  the  bone. 

No  exfoliation  was  found  in  the  matter,  or  on  the  membrane; 
the  dura  mater  lay  at  a  considerable  distance  from  the  scull,  in 
that  part;  the  discharge  from  within  was  large  and  very  offensive; 
and  about  three  weeks  from  the  time  of  opening,  she  died  sud- 
denly in  a  kind  of  fit. 


CASE  XV. 

In  the  middle  of  September  1763,  a  woman  about  sixty  years 
old  fell  down  stairs  backwards;  she  was  stunned  by  the  blow 
which  her  head  received  from  one  of  the  steps,  and  lay  senseless 
some  time. 


92  INJURIES  OP  THE  HEAD 

There  was  neither  wound  nor  considerable  bruise;  she  was  let 
blood,  and  kept  quiet  for  some  few  days;  at  the  end  of 'which, 
finding  no  inconvenience  either  general  or  particular,  she  ceased 
to  regard  it. 

On  the  eighteenth  of  December,  she  was  taken  into  the  hospi- 
tal, for  a  swelling  on  the  right  side  of  her  head,  nearly  of  the  size 
of  a  split  Seville  orange.  This  tumor,  she  said,  had  been  pre- 
ceded by  a  severe  head-ach  without  fever;  but  as  she  did  not  then 
believe  that  her  fall  had  any  share  in  the  production  of  her  pre- 
sent complaint,  she  said  nothing  about  it. 

Her  head  being  shaved,  the  tumor  appeared  full  of  fluid.  I 
divided  the  scalp,  and  let  out  a  quantity  of  greasy  offensive  mat- 
ter. Upon  further  examination,  the  bone  was  found  to  be  bare 
and  carious.  I  removed  such  a  portion  of  scalp  as  brought  the 
whole  into  view.  The  natural  texture  of  the  bone  was  destroyed, 
and  in  it  were  several  holes,  through  which  a  probe  might  easily 
be  passed,  and  from  which  matter  was  discharged  in  such  manner, 
and  with  such  motion,  as  plainly  proved  that  it  came  from  with- 
in the  cavity  of  the  scull. 

She  remained  in  the  hospital  until  the  middle  of  March  ;  dur- 
ing which  time  no  alteration  appeared  in  any  part  of  the  bare 
bone. 

The  affairs  of  her  family  now  required  her  to  be  at  home. 
She  was  in  perfect  good  health;  was  discharged  from  the  hospi- 
tal; and  as  she  lived  very  near  to  me,  one  of  my  young  gentlemen 
undertook  to  take  care  of  her.  On  the  twenty-eighth  of  March, 
1764,  a  small  part  of  the  bare  bone  came  away,  and  left  the 
dura  mater  covered  by  an  healthy  incarnation;  and  on  the  twelfth 
of  April  following,  the  whole  remainder,  being  about  a  third 
part  of  the  parietal  bone,  did  the  same.  From  first  to  last  she 
had  no  kind  of  uneasiness,  and  the  sore  healed  without  any 
trouble. 


CASE  ^XVI. 

In  that  ever  memorable  defence,  made  by  Capt.  Gilchrist,  ou 
board  (as  I  think)  the  Southampton  man  of  war,  against  a  most 


TROM  EXTERNAL  VIOLENCE.  93 

shameful  superiority  of  French  force,  a  sailor  received  a  severe 
blow  on  his  head  by  a  large  splinter:  a  small  wound  and  a  con- 
siderable bruise  were  the  immediate  consequence;  but  they  were 
so 'soon  well,  that  the  man  did  duty  in  a  few  days.  At  about 
seven  weeks  distance  from  the  time  of  the  accident,  he  began  to 
complain  of  great  pain  in  his  head;  which  pain  in  a  few  days 
rendered  him  so  incapable,  that  he  was  put  into  the  hospital  at 
Gosport.  He  remained  there  about  three  weeks,  frequently  but 
not  constantly  in  pain;  and  during  that  time  had  three  or  four 
jfits,  like  epileptic  ones. 

He  was  now  sent  to  St.  Bartholomew's  hospital,  and  put  under 
the  care  of  Dr.  Pitcairn,  by  whose  order  he  was  bled,  purged, 
and  took  several  medicines.  The  man  having  one  day  mention- 
ied  the  circumstance  of  the  blow,  the  doctor  desired  that  I  might 
examine  him. 

There  was  not  the  least  degree  of  swelling  or  inflammation,  no 
mark  or  vestige  of  a  scar,  nor  any  elevation  of  the  scalp,  or  fluc- 
tuation of  fluid,  under  it.  While  I  was  examining  his  head,  he 
had  a  slight  attack  of  spasm;  but  on  my  desisting  he  became 
easy  and  tranquil. 

The  circumstance  of  this  attack,  while  I  was  pressing  upon 
the  part,  did  not  at  that  instant  strike  me  as  worthy  notice,  but 
upon  reflection  it  appeared  much  so.  The  next  day  I  made  the 
same  experiment,  with  the  same  eflfect;  that  is,  upon  hard  pres- 
sure he  became  convulsed,  which  convulsion  ceased  upon  re- 
moving the  fingers,  but  was  followed  by  a  rigor.  On  the  follow- 
ing day  I  ventured  to  repeat  the  experiment;  but  the  man  was  so 
immediately  and  so  terribly  convulsed,  that  J  determined  never 
to  try  it  again. 

I  informed  his  physician  of  all  that  had  passed,  and  we 
agreed,  that  considering  the  inefficacy  of  all  that  4iad  hitherto 
been  done,  and  what  had  lately  happened,  the  most  probable  me- 
thod of  attempting  his  relief  would  be,  by  denuding  and  perhaps 
perforating  the  cranium,  in  the  place  where  the  pressure  produced 
so  strange  an  effect. 

The  next  day  I  removed  a  circular  piece  of  the  scalp,  and 
found  the  pericranium  not  of  a  healthy  or  sound  colour,  nor  ad- 
herent to  the  bone;  which  bone  was  carious,  and  had  several 


94  INJURIES  OF    THE    HEAD 

small  holes  iu  it,  through  which  a  sanies  rose  and  fell,  according 
to  the  motion  of  the  blood  in  the  brain.  I  applied  a  large  tre- 
phine, without  any  regard  to  the  suture,  and  removed  a  piece  of 
scull.  During  the  time  of  the  operation,  the  poor  man  suffered 
greatly  from  spasm;  but  that  over,  he  became  easy  and  quiet. 

The  dura  mater  was  detached  from  the  scull,  and  had  matter  on 
its  surface;  which  matter  was  extremely  offensive.  The  ensuing 
night  he  passed  ill;  and  the  next  day  had  such  a  rigor,  that  I 
verily  thought  it  was  the  last  trouble  the  man  could  have.  The 
day  after  this  I  found  him  vastly  better;  the  discharge  from  his 
head  had  been  large,  but  he  had  not  suffered  any  return  eiiher 
of  spasm  or  rigor,  and  his  principal  complaint  was  extreme  low- 
ness. 

The  physician  prescribed  for  him  ;  his  medicines  agreed  well 
with  him,  and  every  thing  for  several  days  wore  a  favourable 
aspect.  On  a  sudden  he  was  seized  with  all  the  symptoms  of  a 
peripneumony,  and,  on  the  third  day  from  that  seizure,  died.  No 
apparent  cause  of  mischief  was  found  either  within  or  on  the 
outside  of  the  head,  the  dura  mater  was  well  incarned,  and  no 
lodgement  of  matter. 


SECT.  IV. 


FISSURES  AND    FRACTURES  OF    THE  CRANIUM,  WITHOUT    DEPRES- 
SION. 

Fractures  of  the  cranium  were,  by  the  ancient  writers,  di- 
vided into  many  different  sorts,  each  of  which  was  distinguished 
by  an  appellation  of  Greek  etymology,  borrowed  either  from  the 
figure  of  the  fracture,  or  the  disposition  of  the  broken  pieces. 
These  are  to  be  found  in  most  of  the  old  books;  but  as  they  merely 
load  the  memory,  without  informing  the  understanding,  or 
assisting  the  practitioner,  modern  authors  have  generally  laid  them 
aside. 

This  kind  of  injury  is  divisible  into  two  general  heads;  viz. 
those  iu  which  the  broken  parts  keep  their  proper  level,  or  equality 


FROM  EXTERNAL  VIOLENCE.  96 

of  surface,  with  the  rest  of  tlie  scull,  and  those  In  which  they  do 
not;  or,  in  other  words,  fractures  without  depression^  and  frac- 
tures with. 

These  two  distinctions  are  all  which  are  really  necessary  to  be 
made,  and  will  be  found  to  comprehend  every  violent  division 
of  the  parts  of  the  scull,  (not  made  by  a  cutting  instrument,)  from 
the  finest  capillary  fissure,  up  to  the  most  complicated  fracture: 
for  fissures  and  fractures,  differing  from  each  other  only  in  the 
width  of  the  breach,  or  in  the  distance  of  the  separated  parts,  and 
the  disposition  of  broken  pieces  in  large  fractures  being  subject  to 
an  almost  infinite  variety,  distinctions  and  appellations  drawn  and 
made  from  these  circumstances  might  be  multiplied  to  even  three 
times  the  old  number,  without  imparting  the  smallest  degree  of 
useful  knowledge  to  the  man  who  should  be  at  the  pains  to  get 
them  by  heart. 

What  are  the  symptoms  of  a  fractured  cranium.'*  is  often  asked; 
and  there  is  hardly  any  one  who  does  not,  from  the  authority  of 
writers,  both  ancient  and  modern,  answer,  vomiting,  giddiness, 
loss  of  sense,  speech,  and  voluntary  motion,  bleeding  at  the  ears, 
nose  and  mouth,  &c.  This  is  the  doctrine  of  Celsus,  which  has 
been  most  invariably  copied  by  almost  all  succeeding  authors,  and 
implicitly  believed  by  almost  all  readers.^ 

The  symptoms  just  mentioned  do  indeed  very  frequently  ac- 
company a  broken  scull,  but  they  are  not  produced  by  the  breach 
made  in  the  bone;  nor  do  they  indicate  such  breach  to  have  been 
made.  They  proceed  from  an  affection  of  the  brain,  or  from  in- 
jury done  to  some  of  the  parts  within  the  cranium,  independent  of 
any  ill  which  the  bones  composing  it  may  have  sustained.  They 
are  occasioned  by  violence  offered  to  the  contents  of  the  head  in 
general;  are  quite  independent  of  the  mere  breach  made  in  the 
bone;  and  either  do  or  do  not  accompany  fracture,  as  such 
fracture  may  happen  to  be  or  not  to  be  complicated  with  such 
other  ills. 


^  "  Igitur  ubi  percussa  est  calvaria,  protinus  requirendum  est,  num  bilem 
"is  homo  vomuerit,  num  oculi  ejus  obcsecati  sint;  num  per  nares,  uuresve 
"sanguis  ei  efHiixerit;  num  conciderit;  num  sine  sensu  quasi  dormiens 
"jacuerit?  &c.  hsc  enim  non  nisiossefrcicto  eveniunt." 


&6'  INJURIES  OP  THE  HEAD 

They  are  frequeatly  produced  by  extravasations  of  blood,  or 
serum,  upon,  or  between  the  membranes  of  the  brain;  or  by 
shocks,  or  concussions  of  its  substance,  in  cases  where  the  scull  is 
perfectly  entire  and  unhurt.  On  the  other  hand,  the  bones  of  the 
scull  are  sometimes  cracked,  broken,  nay  even  depressed,  and  the 
patient  suiTers  none  of  these  symptoms.*  In  short,  as  the  breach 
made  in  the  bone  is  not,  nor  can  be  the  cause  of  such  complaints, 
they  ought  not  to  be  attributed  to  it;  and  that  for  reasons  which 
are  by  no  means  merely  speculative.  For  the  practitioner,  who 
supposes  that  such  symptoms  do  necessarily  and  certainly  imply 
that  the  cranium  is  fractured,  must  regulate  his  conduct  by  such 
supposition,  and  remove  the  scalp,  very  often  without  either  neces- 
sity or  benefit;  that  is,  without  discovering  what  he  looks  for:  and, 
on  the  other  hand,  if  he  does  find  the  scull  to  be  broken,  believing 
all  these  complaints  to  be  caused  by,  and  deducible  from  the  frac- 
ture, he  will  most  probably  pay  his  whole  attention  to  that  sup- 
posed cause,  and  may  think,  that  when  he  has  done  what  the 
rules  of  his  art  prescribe  for  such  case,  he  has  done  all  that  is 
in  his  powder — an  opinion  not  infrequently  embraced;  and  which 
has  been  the  destruction  of  many  a  patient.  For,  as  on  the  one 
hand,  the  loss  of  sense,  speech,  and  voluntary  motion,  as  well  as 
the  hagmorrhage  from  the  nose,  ears,  &c.  are  sometimes  totally 
removed  by,  or  at  least  disappear  during  the  use  of  free  and  fre- 
quent evacuation,  without  any  operation  on  the  scalp  or  scull;  so 
on  the  other,  as  these  symptoms  and  appearances  are  not  produc- 
ed by  the  solution  of  continuity  of  the  bone,  they  cannot  be  reme- 
died by  such  chirurgic  treatment  as  the  mere  fracture  may 
require. 

a  "  Si  Ixsiis  instar  dormientis  sensus  expers  deprehendatur ;  si  oculi  ejus 
*'  obcaccati  fuerint ;  si  obmutuerit ;  si  bilem  vomuerit ;  si  animalis  instar 
"  malleo  icti  concideiit ;  hrec  omnia  maximam  et  subitaneam  significant  cere- 
"  bri  commotionem,  pertiirbationein,  ac  concussionem  qiite  no7i  rara  integro 
"  maneiite,  nee  vlla  ex  parte  rupto  cramo,  mortem  percusso  adferunt." 

Pet.  Paaw. 

"  Dans  les  playes  de  lete,  les  accidens  que  les  auteurs  anciens  ont  appelles 
"  primitifs,  parcequ'ils  arrivent  dans  I'instant  meme  de  la  blessure,  ne  sont 
"  nullcment  des  accidens,  ni  des  signes,  de  la  fracture  subsistante,  mais  des 
"accidensj  &  des  signes,  de  la  commotion  de  cerveau." 

Le  Dbak. 


FROM  EXTERNAL  VIOLENCE.  97 

If  any  one  doubt  the  truth  of  this  doctrine,  I  would  desire  him 
to  consider  the  nature,  as  well  as  the  most  generally  successful 
method  of  treating  these  symptoms;  and,  at  the  same  time,  to  re- 
flect seriously  on  the  operation  of  the  trepan,  as  practised  in  simple, 
undepressed  fractures  of  the  scull. 

'  The  sickness,  giddiness,  vomiting,  and  loss  of  sense  and  motion, 
can  only  be  the  consequences  of  an  affection  of  the  brain,  as  the 
common  sensorium.  They  may  be  produced  by  its  having  been 
violently  shaken,  by  a  derangement  of  its  medullary  structure,  or 
by  unnatural  pressure,  made  by  a  fluid  extravasated  on  its  surface, 
or  within  its  ventricles;  but  never  can  be  caused  by  the  mere 
division  of  the  bone,  (considered  abstractedly,)  which  division,  in 
a  simple  fracture,  can  neither  press  on  nor  derange  the  structure  of 
the  parts  within  the  cranium. 

If  the  solution  of  continuity  in  the  bone  be  either  produced  by 
such  a  degree  of  violence,  as  hath  caused  a  considerable  disturb- 
ance in  the  medullary  parts  of  the  brain,  or  has  disturbed  any  of 
the  functions  of  the  nerves  going  off"  from  it,  or  has  occasioned  a 
breach  of  any  vessel,  or  vessels,  whether  sanguine  or  lymphatic, 
and  that  hath  been  followed  by  an  extravasation,  or  lodgement  of 
fluid,  the  symptoms  necessarily  consequent  upon  such  derange- 
ment, or  such  pressure,  will  follow;  but  they  do  not  follow  be- 
cause the  bone  is  broken;  their  causes  are  superadded  to  the  frac- 
ture, and  although  produced  by  the  same  external  violence,  are  yet 
perfectly  and  absolutely  independent  of  it;  so  much  so,  that,  as  I 
have  already  observed,  they  are  frequently  found  where  no  frac- 
ture is. 

The  operation  of  the  trepan  is  frequently  performed  in  the  case 
of  simple  fractures,  and  that  very  judiciously  and  properly;  but  it 
is  not  performed  because  the  bone  is  broken,  or  cracked:  a  mere 
fracture,  or  fissure  of  the  scull,  can  never  require  perforation,  or 
that  the  dura  mater  under  it  be  laid  bare;  the  reason  for  doing  this 
springs  from  other  causes  than  the  fracture,  and  those  really  inde- 
pendent on  it.  They  spring  from  the  nature  of  the  mischief  which 
the  parts  within  the  cranium  have  sustained,  and  not  from  the  ac- 
cidental division  of  the  bone.  From  these  arise  the  threatening 
symptoms;  from  these  all  the  hazard;  and  from  these  the  necessity 
and  vindication  of  performing  the  operation  of  the  trepan. 

VOL.  I.  N 


98  INJURIES  OF  THE  HEAD 

If  a  simple  fracture  of  the  cranium  were  unattended  in  present 
with  any  of  the  before-mentioned  symptoms,  and  there  were  no 
reason  for  apprehending  any  otlier  pvil  in  future,  that  is,  if  the  so- 
lution of  continuity  in  the  bone  were  the  whole  disease,  it  could 
not  possibly  indicate  any  other  curative  intention,  but  the  general 
one  in  all  fractures;  viz.  union  of  the  divided  parts.  But  how  can 
such  union  be  promoted  or  assisted  by  perforation?  it  most  cer- 
tainly cannot;  and  yet  perforation  is  absolutely  necessary  in  seven 
cases  out  of  ten,  of  simple  undepressed  fractures  of  the  scull.  Let 
us  for  a  moment  inquire  why  it  is  so.  The  reasons  for  trepanning 
in  these  cases  are,  first,  the  immediate  relief  of  present  symptoms 
arising  from  pressure  of  extravasated  fluid;  or  second,  the  discharge 
of  matter  formed  between  the  scull  and  dura  mater,  in  consequence 
of  inflammation;  or  third,  the  prevention  of  such  mischief,  as  ex- 
perience has  shown  may  most  probably  be  expected  from  such  kind 
of  violence  oifered  to  the  last-mentioned  membrane  These  are 
the  only  reasons  that  can  be  given  for  perforating  the  scull,  in  the , 
case  of  an  undepressed  fracture;  and  very  good  and  very  justifiable 
reasons  they  are,  but  not  drawn  from  the  fracture. 

In  the  first  case  (that  of  an  extravasated  fluid  within  the  cra- 
nium), the  relief  from  perforation  is  not  only  sometimes  imme- 
diate, but  frequently  is  not  attainable  by  any  other  means.  This 
is  a  sufficient  proof,  not  only  of  its  utility,  but  of  its  necessity. 

In  the  second,  of  formation  of  matter  (between  the  scull  and 
dura  mater),  it  is  the  unicum  remedium;  there  is  no  natural  outlet 
by  which  such  matter  can  escape;  and  the  only  chance  of  life  is 
from  the  operation. 

In  the  third,  that  of  mere  fracture  without  depression  of  bone^ 
or  the  appearance  of  such  symptoms  as  indicate  commotion,  extra- 
vasation, or  inflammation,  it  is  used  as  a  preventative,  and  there- 
fore is  a  matter  of  choice,  more  than  immediate  necessity. 

Many  practitioners,  both  ancient  and  modern,  have  therefore 
disused  and  condemned  it;  and  have,  in  cases  where  there  have 
been  no  immediate  bad  symptoms,  advised  us  to  leave  the  fracture 
to  nature,  and  not  to  perform  the  operation  as  a  preventative,  but 
to  wait  until  its  necessity  may  be  indicated  by  such  symptoms  as 
may  both  require  and  vindicate  it.     This  is  a  point  of  the  ut- 


FROM  EXTERNAL  VIOLENCE.  99 

most  consequence  in  practice,  and  ought  to  be  very  maturely 
considered. 

They  who  object  to  the  early  use  of  the  trephine,  speak  of  it  as 
being  frequently  unnecessary,  and  as  rendering  the  patient  liable 
to  several  inconveniences  which  may  arise  from  uncovering  the 
dura  mater,  before  there  is  any  good,  or  at  least  any  apparent 
reason  for  so  doing.  And,  in  support  of  this  their  opinion,  they 
allege  many  instances  of  simple  fracture  which  have  been  long 
undiscovered,  without  being  attended  with  any  bad  symptoms; 
and  of  others  which,  though  known  and  attended  to  from  the  first, 
have  done  very  ipvell  without  such  operation. 

They  who  advise  the  immediate  use  of  the  instrument  do  it 
upon  a  presumption,  that,  in  considerable  violence  received  by  the 
head,  such  mischief  is  done  to  the  dura  mater,  and  the  vessels  by 
which  it  is  connected  to  the  cranium,  that  inflammation  of  the  said 
membrane  must  follow;  which  inflammation  generally  produces  a 
collection  of  matter,  and  a  symptomatic  fever,  which  most  fre- 
quently baffles  all  our  art,  and  ends  in  the  destruction  of  the  pa- 
tient. 

What  the  former  assert  is  undoubtedly  sometimes  true.  There 
have  been  several  instances  of  undepressed  fractures  of  the  scull, 
which,  either  from  having  been  undiscovered  at  first,  or  neglected, 
or  having  been  under  the  care  of  a  practitioner  who  had  disliked 
the  operation,  have  done  very  well  without  it.  This  is  certainly 
true,  but  is  not  sufficient  to  found  a  general  rule  of  practice  upon: 
in  matters  of  this  sort,  a  few  instances  are  by  no  means  sufficient 
to  establish  a  precedent:  what  has  been,  or  may  accidentally  prove 
beneficial  to  a  few,  may  be  pernicious  to  the  multitude:  that 
which  is  found  to  be  most  frequently  useful,  is  what  we  ought  to 
abide  by,  reserving  to  ourselves  a  liberty  of  deviating  from  such 
general  rule  in  particular  cases. 

This  is  one  of  those  perplexing  circumstances,  which  all  writers 
lament,  and  all  practitioners  feel,  but  which,  instead  of  merely 
complaining  of,  we  should  endeavour,  as  much  as  in  us  lies,  to 
correct. 

In  order  to  obtain  what  information  we  can  on  this  subject,  we 
should  consider,  first,  what  the  mischiefs  are  which  may  most  pro- 
bably be  expected  to  follow,  or  which  most  frequently  do  follow. 


100  INJURIES  OP  THE  HEAD 

when  perforation  has  been  too  long  defended,  or  totally  neglected; 
secondly,  what  prejudice  or  inconvenience  does  really  arise  from, 
or  is  thought  to  be  caused  by  the  operatibn  itself,  considered  ab- 
stractedly; and  thirdly,  what  proportion  the  number  of  those  who 
have  done  well  without  it,  bears  to  that  of  those  who  may  truly  be 
said  to  have  been  lost  for  want  of  it,  or  of  those  to  whom  it  might 
have  afforded  some  chance  of  relief. 

With  regard  to  the  first,  I  have  already  observed  in  the  case  of 
simple  undepressed  fractures,  whenever  the  trephine  is  applied,  it 
must  be  with  design  either  to  relieve,  or  to  prevent  ills  arising 
from  other  mischief  than  the  mere  breach  in  the  bone;  which 
breach,  considered  simply  and  abstractedly,  can  neither  cause 
such  ills,  nor  be  relieved  by  such  operation.  Oiie,  and  that  the 
most  frequent  of  these  mischiefs,  is  the  inflammation,  detach- 
ment, and  suppuration  of  the  dura  matter,  and  consequently  the 
collection  of  matter  between  it  and  the  scull;  a  case,  of  all  others 
attending  wounds  of  the  head,  the  most  pressing,  the  most  hazard- 
ous, and  the  least  within  our  power  to  relieve.  On  this  subject  I 
have  expressed  my  sentiments  so  much  at  large,  under  the  pre- 
ceding article  contusion,  that  it  is  needless  to  repeat  them  here.  I 
shall  therefore  take  the  liberty  of  referring  the  reader  back  to 
that,  and  only  remind  him  of  a  circumstance  well  worth  his  attend-, 
ing  to;  viz.  that  there  are  no  immediate  or  early  marks  or  symp- 
toms, whereby  he  can  certainly  know,  whether  such  kind  of  mis- 
chief is  done  or  not;  and  that,  when  such  complaints  come  on  as 
indicate  that  such  mischief  has  been  received,  although  the  opera- 
tion is  all  that  is  in  our  power  to  do,  yet  it  is  very  frequently  un- 
successful.''    Indeed,  the  only  probable  method  of  preventing  this 

•»  The  state  of  the  dura  mater,  under  simple  fractures  and  fissui'es  of  the 
cranium,  has  been  very  nicely  observed,  and  very  justly  described,  by  some 
of  the  best  writers  of  antiquity. 

"  Si  ad  cerebri  membranam  usque  pervenerit  fractnra,  non  redemus,  sed 
"  agnoscere  conabimur  utrum  membrana  ab  osse  recesserit,  an  affixa  perma- 
"  neat.  Si  enim  ipsa  manet,  inflammatio  nulla  infestat  vulnus,  etpus  coc- 
••  turn  apparet.  Si  cesserit  membrina,  augeiitur  dolores,  et  febris  similiter; 
"  OS  alium  sumit  colorem  ;  pus  tenue,  et  crudum  eff'ertur ;  et  si  medicus  ne- 
"  gligenter  rem  tractat,  nee  perforatio?ie  ulitur,  hoc  graviora  symj)tomata 
"aboriuntur;  nempe  bilis  voinitus,  convulsio,  mentis  delirium,  et  febris 
"acuta."  Paclvs  jEcfiK;;;TA, 


PROM  EXTERNAL  VIOLENCE.  101 

evil  seems  to  be,  the  removal  of  such  a  part  of  the  scull,  as  by  be- 
ing broken  appears  plainly  to  have  been  the  part  where  the  vio- 
lence was  inflicted;  and  which,  if  the  dura  mater  becomes  in- 
flamed, and  quitting  its  connexion  suppurates,  will,  in  all  probabi- 
lity, cover  and  confine  a  collection  of  matter  for  which  nature  has 
provided  no  outlet.  This  I  take  to  be,  not  only  the  best,  but  the 
only  good  reason,  for  the  early  use  of  the  trephine  in  simple  unde- 
pressed fractures  of  the  scull:  and  I  must  add,  that  it  appears  to  me 
to  be  fully  sufficient  to  vindicate  and  authorise  it.  That  it  frequently 
fails  of  success  is  beyond  all  doubt;  the  extent  and  degree  of  the 
mischief  being  too  great  for  it  to  relieve:  but  that  it  has  preserved 
many  a  life,  which  must  have  been  lost  without  it,  I  am  as  well 
satisfied  of,  as  I  am  of  any  truth  which  repeated  experience  may 
have  taught  me. 

In  matters  of  this  sort,  positive  proof  and  conviction  are  not  in 
our  power;  all  that  we  can  do  is,  by  making  a  comparison  of 
the  conduct  and  event  of  a  number  of  similar  cases,  to  come  as 
Hear  to  truth  as  we  can,  and  to  get  probability  on  our  side. 

The  second  consideration  which  I  proposed  to  be  made  was, 
what  mischief  or  inconvenience  may  most  reasonably  be  supposed 
to  follow,  or  to  proceed  from  the  mere  operation  considered  ab- 
stractedly. They  who  are  averse  to  the  use  of  it,  as  a  preventative, 
allege  that  it  occasions  a  great  loss  of  time;  that  it  is  frequently 
quite  unnecessary;  and,  that  the  admission  of  air  to  the  dura 
mater,  as  well  as  the  laying  of  it  bare,  is  necessarily  prejudicial. 

The  former  of  these  is  undoubtedly  true;  a  person,  whose  scull 
has  been  perforated,  cannot  possibly  be  well  (that  is,  cured)  in  so 
short  a  space  of  time,  as  one  who  has  not  undergone  such  opera- 

"  Dico  debet  dari  signum  fractura,  a  qua  removeatur  pafiniculus  grossus. 
"  In  primo  debes  scire  dispositionem  syphs  ;  utnitn  est  adherens,  an  non  ;  vi- 
"  delicet,  si  ad!i?eserit  ossi  non  fiet  in  viilnus  apostema  calidum  ;  et  licet  ac- 
"  cidit,  modicum  erit;  senigo  manabit  de  eo  modica;  et  putredo  erit  di* 
"  gesta.  Sed  si  faerit  remotus,  vehementiores  erunt  dolores,  et  febres,  mu- 
"  tabitur  color   ossis,  et  corrumpetur,  et  manebit  de  eo  putredo  tenuis." 

Rhazes. 

"  Si  rinia  sit  in  superficie,  cerebri  membrana  non  abscedente,  eadem  ad- 
"  hibeatur,  qiije  ad  os  nudatum  demonstrata  est :  cerebri  vero  membrana  ab- 
"  scedente,  et  humore  ibi  collecto,  post  primos  cnrationis  dies  ad  terebram 
"  properandum  est,"  &c^  jDbtbasit-s, 


102  INJURIES  OF  THE  HEAD 

-tion;  supposing  such  person  to  have  sustained  no  other  injury  than 
-the  mere  fracture  :  and  if  the  majority  of  the  people  whose  sculls 
are  broken  were  to  sustain  no  other  iiijury,  that  is,  if  no  oiher 
mischief  were  in  these  cases  in  general  done  to  the  parts  con- 
tained within  the  scull,  the  objection  to  perforation  would  be  real 
and  great,  and  the  operation  a  matter  of  more  serious  considera- 
tion. But  this  is  seldom,  too  seldom  the  case;  by  much  the  larger 
number  of  those  who  suffer  a  fracture  of  the  scull  are  injured 
with  regard  to  other  parts,  and  labour  under  mischief  of  another 
kind,  additional  to  the  fracture;  that  is,  the  parts  within  the  cra- 
nium are  injured  as  well  as  the  cranium  itself.  This  being  the 
case,  the  loss  or  waste  of  a  little  time  ceases  to  be  an  object  of  so 
;great  importance.  The  hazard  which  it  is  supposed  may  be  in- 
curred from  laying  bare  the  dura  mater,  is  indeed  a  matter  of 
some  weight,  so  much  so,  that  it  certainly  ought  not  to  be  done, 
but  for  very  good  reasons;  and  yet,  although  I  am  clearly  of  this 
opinion,  I  think  that  I  may  venture  to  say,  that,  let  the  supposed 
hazard  be  what  it  may^  it  cannot  in  the  nature  of  things  be  by 
any  means  equal  to  that  which  mu^  be  incurred  by  not  doing  it, 
when  such  operation  becomes  necessary.  In  short,  if  we  would 
form  a  right  judgment  of  this  point,  the  question  concerning  it 
ought  to  stand  thus:  Is  the  chance  of  ill  which  may  proceed  from 
merely  denuding  the  dura  mater,  equal  to  that  of  its  being  so  hurt 
by  the  blow,  as  to  inflame  and  suppurate?  Or  is  the  mischief 
which  may  be  incurred  by  mere  perforation  of  the  scull,  equal  to 
the  good  which  it  may  produce?  These  questions,  let  those  who 
have  seen  most  business  of  this  kind,  and  who  are  therefore  the 
best  judges,  consider  and  determine.  For  my  own  part,  I  have 
no  doubt,  that  although,  by  establishing  it  as  a  general  rule  to  per- 
forate in  all  cases,  some  few  would  now  and  then  be  subjected  to 
the  operation,  who  might  have  done  very  well  without  it;  yet,  by 
the  same  practice,  many  a  valuable  life  would  be  preserved,  which 
must  inevitably  be  lost  without  it,  there  being  no  degree  of  com- 
parison between  the  good  to  be  derived  from  it,  when  used  early, 
as  a  preventative,  and  what  may  be  expected,  if  it  be  deferred  till 
an  inflammation  of  the  dura  mater  and  a  symptomatic  fever 
make  it  necessary. 


PROM  EXTEraMAL  VIOLENCE.  103 

The  third  consideration,  viz.  what  proportion  the  number  of 
those  who  have  escaped  without  the  operation  bears  to  that  of 
those  who  have  perished  for  want  of  it,  is  in  great  measure  in- 
cluded in  the  two  preceding;  at  least  the  determination  of  them 
must  also  determine  this. 

My  own  opinion  must,  till  I  find  reason  to  alter  it,  be  the  rule 
of  my  own  conduct;  and  though  I  would  not  by  any  means 
pretend  to  obtrude  the  former  on  any  one,  yet  I  think  it  in  some 
measure  incumbent  upon  me  in  this  place  to  give  it. 

The  number  of  cases  of  this  kind,  which  are  necessarily  brought 
into  a  large  hospital  so  situated  as  Bartholomew's  is,  in  the  midst 
of  a  populous  city,  where  all  kinds  of  hazardous  labour  are 
carried  on,  has  enabled  me  to  make  many  observations  on  them; 
and  although  I  have  now  and  then  seen  some  few  of  them  do  well 
without  the  use  of  the  trephine,  yet,  the  much  greater  number, 
whom  I  have  seen  perish  with  collections  of  matter  within  the 
cranium,  who  have  not  been  perforated,  and  from  whom  there  is 
no  other  relief  in  art  or  nature,  has,  1  must  acknowledge,  ren- 
dered me  so  very  cautious  and  diffident,  that  although  I  will  not 
say,  that  I  would  always  and  invariably  perform  the  operation  in 
every  case  of  simple  fracture,  yet  the  case  must  be  particularly 
circumstanced,  the  prospect  much  fairer  than  it  most  frequently^ 
is,  and  my  prognostic  delivered  in  the  most  grounded  apprehen- 
sive manner,  when  I  omit  it.  I  should  be  sorry  to  be  so  misun- 
derstood, as  to  have  it  supposed  that  I  mean  to  say,  that  I  think 
the  denudation  of  the  dura  mater  a  matter  of  absolute  indiffer- 
ence, or  that  no  ill  can  proceed  from  it;  this,  I  know,  is  a  point 
concerning  which  the  best  practitioners  have  differed,  and  con- 
cerning which  we  still  stand  in  need  of  information;  but  T  think  I 
may  venture  to  say,  what  is  fully  to  my  present  purpose,  viz.  that 
enlarging  the  opening  of  a  fracture,  by  means  of  a  trephine,  will 
not  produce  or  occasion  much  risk  or  hazard,  additional  to  what 
must  be  occasioned  by  the  fracture  itself,  that  has  already  let  in 
air  upon  the  membrane,''  and  therefore  that  consideration  is,  at 

'  It  is  to  be  remarked,  that  Mr.  Pott  has  in  this  place  been  speakingof  sim- 
pie  fractures  of  the  cranium  without  depression,  in  which  he  appears  inclin- 
ed to  recommend  the  use  of  the  trephine  as  a  preventative.  I  must  confess 


104  INJURIES  OF  THE  HEAD 

least  in  some  degree,  at  an  end;  and  the  principal  point  to  be  de- 
termined still  remains  the  same,  viz.  whether,  upon  a  supposition 
that  the  dura  mater  rnaj  possibly  not  have  been  so  injured  as  to 
inflame  and  suppurate  in  future,  the  operation  ought  not  to  be 
practised  as  a  preventative,  but,  on  the  contrary,  ought  rather  to 
be  deferred  until  worse  symptoms  indicate  the  necessity  of  it?  or 
whether  it  ought  in  general  to  be  performed  early,  in  order,  if  pos- 
sible, to  prevent  and  guard  against  very  probable,  as  well  as  very 
terrible  mischief? 

I  know  that  it  may  be  said,  that  a  fracture,  if  of  any  consider- 
able size,  or  whose  edges  are  fairly  distant  and  unconnected,  will 
of  itself  make  some  way  for  discharge  from  within;  and  so  it  cer- 
tainly may,  and  does,  in  the  case  of  an  effusion  of  fluid  blood;  but 
even  in  this  it  very  seldom  proves  sufficient  for  the  purpose.  But 
does  not  the  distant  separation  of  the  edges  imply  greater  separa- 
tion of  the  attaching  vessels  of  the  dura  mater?  and  does  not  ex- 
perience too  often  prove  this  to  be  the  case?  In  truth,  the  great 
advantage  which  is  sometimes  derived  from  considerable  frac- 
tures, is  most  frequent  in  those  cases  where  portions  of  bone  are 
so  loose  as  to  be  removeable,  which  removal  of  bone  stands  in 
place  of  perforation,  and  makes  much  more  for  the  necessity  of 
the  operation  in  other  cases  than  against  it,  if  properly  consi- 
dered. 

I  may  possibly  be  told,  that  Hildanus  Wiseman,  arid  others  of 
great  and  deserved  reputation,  have  been  of  the  former  opinion. 
I  know  they  have;  and  when  I  differ  from  these,  or  any  other 

I  cannot  clearly  perceive  how  a  simple  crack  or  fissure  through  the  scuU 
can  be  said  to  let  in  air  upon  the  membrane;  or,  if  it  did,  that  it  should  be  a 
reason  for  uncovering  a  greater  part  of  it. 

If  I  may  take  the  liberty,  after  such  great  autliority,  to  offer  my  opinion,  I 
must  say  that  I  do  not  think  the  operation  with  the  trephine  is  to  be  con- 
sidered of  lightly.  If  the  injury  which  has  been  received  be  sufficient  to 
produce  mischief,  we  are  by  no  means  certain  of  finding  the  seat  of  it,  nor  of 
preventing  it  by  making  an  opening.  I  am  therefore  decicl^dly  against  ap- 
plying the  trephine  after  every  simple  fracture  or  fissure,  and  think  it  better 
to  defer  the  operation,  till  some  symptoms  indicate  the  necessity  of  it.  This 
opinion  is  drawn  from  reasoning  on  the  subject,  and  is  confirmed  by  the 
many  cases  of  simple  fracture  which  I  have  known  got  well  without  any 
such  operation.    E. 


PROM  EXTERNAL  VIOLENCE.  105 

good  authority,  I  hope  that  I  shall  always  do  it  with  caution  and 
diffidence;  but  I  hope  also,  that  I  shall  never  hesitate  to  differ  from 
any  and  every  authority,  when  I  think  that  I  have  truth  on  my 
side,  and  the  good  of  mankind  in  my  view.  The  above-mentioned 
writers,  together  with  almost  all  their  contemporaries,  had,  in 
simple  fractures  of  the  scull,  but  one  contemplation,  the  extrava- 
sation of  blood;  this  they  regarded  as  the  cause  both  of  the  early 
symptoms  and  of  the  late  ones;  considering  it  as  acting  either  by 
pressure  or  putrefaction;  and  therefore,  when  there  was  no  im- 
mediate sign  of  such  extravasation  from  the  effects  of  pressure, 
they  saw  no  necessity  for  early  or  immediate  perforation.  But 
had  tUey  not  forgotten  the  universal  adhesion  of  the  dura  mater  to 
the  cranium;  had  they  not,  without  any,  or  indeed  contrary  to  all 
authority  from  anatomy,  formed  to  themselves  an  erroneous  idea 
of  the  disposition  of  those  parts,  with  regard  to  each  other;^  had 
they  conceived  rightly  of  the  consequences  of  an  inflammation  and 
detachment  of  that  membrane,  I  am  much  inclined  to  believe,  that 
they  would  have  altered  their  opinion,  and  not  in  general  have 
left  penetrating  fractures  of  the  scull  to  nature;  although  they 
had,  in  some  measure,  the  authority  of  Celsus  for  so  doing.^ 

^  Some  of  the  writers  of  this  time  speak  of  the  supposed  vacuity  between 
the  dwra  mater  and  scull,  as  being  calculated  for  the  reception  of  extravasated 
fluid,  in  case  of  accident :  which  opinion  reminds  me  of  that  of  a  much  later 
writer,  who  says,  *•  that  the  os  unguis  was  made  so  thin,  for  its  more  easy 
''  perforation  in  the  operation  of  the  fistula  lachrymalis." 

"  "  In  omni  vero  fisso  fractove  osse,  protinus  antiquiores  medici,  ad  ferra- 
"  menta  veniebant  quibus  id  exciderent.  Sed  multo  melius  est  ante  em- 
"  plastra  experiri,  quae  calvarise  causa  componuntur,"  &c. 

Celsus. 

Whoever  has  an  inclination  to  amuse  himself  with  the  different  opinions  of 
different  writers  on  the  subject  of  perforating,  or  not  perforating,  will  find 
them  in  Palfyn,  Rohalt,  and  many  others. 

But  that  the  frequent  ill  effects  of  neglecting  this  operation  were  not  un- 
attended to  by  many,  the  following  quotation,  taken  from  a  number  of  simi- 
lar ones,  may  evince : 

"  Et  scias,  sicut  volunt  veteres,  quod  non  est  excusatio  ab  incisione,  et  re- 
"  motione  cranii,  cum  in  eo  penetrans  fractura  sit ;  et  hsec  propter  duo ; 
"  primo  quod  os  capitis,  sicut  dictum  est,  debilem  facit  porum.  Secundo, 
"  quia  si,  osse  jam  restaurato,  acciderit  interius  (quantocunque  modice)  gene- 
"  ratio  saniei,  vel  alicujus  humoris  superflui  expellendi,  quomodo,  jam  restau- 
"  rato  osse,  posset  expelli,"  &c. 

VOL.  I.  0 


106  INJURIES  OF  THE  HEAD 

Before  I  enter  upon  the  account  of  the  present  and  most  proper 
method  of  treating  simple  undepressed  fractures  of  the  scull,  it 
may  perhaps  be  not  amiss  to  make  a  short  inquiry  into  the  opi- 
nions which  our  remote  ancestors  have  delivered  down  to  us  on 
this  subject,  to  take  a  cursory  view  of  their  intention  and  conduct, 
and  to  examine  whether  the  difference  between  their  practice  and 
ours  be  well  grounded  or  not;  it  being  neither  antiquity  nor  no- 
velty, but  utility  only,  which  can  demand  our  regard. 

That  extravasation  of  blood,  and  formation  of  matter  between 
the  scull  and  membranes  of  the  brain,  were  the  two  principal 
causes  of  bad  symptoms  and  of  death  in  fractures  of  the  cranium, 
and  that  the  only  rational  method  of  obtaining  relief  in  either  case 
was  by  making  such  an  opening  in  the  bone  as  would  give  dis- 
charge to  the  said  fluids,  was  full  as  well  known  to  our  ancestors 
as  to  us.  Their  intention  and  ours,  therefore,  were  essentially 
alike;  and  the  material  difference  between  our  conduct  and  theirs 
consists  in  the  manner  in,  and  the  instruments  by,  which  we  en- 
deavour to  execute  such  intention.  When  the  breach  in  the  bone 
was  small,  and  no  symptoms  of  immediate  extravasation  attended, 
their  principal  apprehension  was,  that  the  sanies,  or  matter,  which 
they  supposed  must  necessarily  be  excreted  from  the  edges  of  the 
fracture,  would  drop  down,  lodge,  and  be  collected  on  the  surface 
of  the  dura  mater. 

To  prevent  this  evil,  they  endeavoured  to  enlarge  the  fracture 
by  abrasion  of  its  edges,  by  means  of  scalpra,  or  rugines.  These 
scalpra  were  many  in  number,  and  various  in  their  size  and  figure, 
according  to  the  opinion  or  whim  of  the  practitioner.  Figures  of 
these  are  to  be  seen  in  many  writers;  in  Andreas  a  Cruce,  in  Scul- 
tetus,  in  Fabritius  ab  Aquapendente,  in  Berengarius,  &c.  &c.  &c. 

"Primum  notabile  est  istud,  quod  in  fractura  cranii  debes  prohibere  apos- 
"  tema,  ne  accidat  in  cerebro  aut  in  panniciilisj  he.  Tertium,  notabile  sit 
"is'ud;  quod  si  intentio  medici  solum  esset,  in  occupatione  solutionis  con- 
"tinuitatis,  vel  fracturs,  stante  apostemate,  multa  mala  accidentia  possent 
'*consequi,  utcorruptio  panniculi  febris,  apoplexia,  rigor,"  &c. 

Bf.htapal. 

*  "  Ex  fracturis  vero  quae  ad  cerebri  membranas  pei-venerunt,  si  simplex 
"  fractura  sit,  angustis  scalpris  utendum ;  sin  cum  contusione  aliqua,  quod 
"contusum  est  excidi  debebit ;  idque  vel  terebellis  prius  in  circuitumfora- 
"  turn,  ac  mox  scalpris  admotis,  vel  protinus  ab  initio  cyeliscis." 

Galen. 


FROM  EXTERNAL  VIOLENCE.  107 

But  whoever  examines  them,  and  attends  to  their  proposed  use. 
will  find  them  liable  to  great  objection  ;  he  will  find  that  the  use 
of  them  must  be  irksome  to  the  patient,  tedious  to  the  operator, 
and  unequal  to  the  end  proposed.  That  by  such  kind  of  instru- 
ment the  opening  of  a  small  fracture  may  be  enlarged,  is  beyond 
all  doubt;  but  if  the  breach  be  at  all  large,  or  of  any  length,  such 
method  of  enlarging  it  must  at  best  be  a  very  operose  one;  it  must 
jar  and  shake  the  patient's  head  immoderately;  if  executed  un- 
skilfully, or  inattentively,  it  must  be  attended  with  hazard  of 
wounding  the  dura  mater;  and  when  finished,  could  not  properly 
answer  the  purpose  for  which  it  was  designed. 

Of  these  defects,  some  of  the  practitioners  were  in  some  measure 
sensible;  and  therefore,  when  the  fracture  was  of  such  size,  or  so 
circumstanced,  that  these  scalpra  abrasoria  would  most  probably 
prove  insufficient,  that  is,  when  the  accident  was  produced  by 
such  force,  or  attended  with  such  degree  of  contusion,  as  to  render 
it  probable  that  the  parts  within  were  injured,  they  did  not  then 
depend  upon  this  method  by  abrasion,  but  had  recourse  to  others 
by  which  they  removed  a  portion  of  the  cranium.^  In  the  execu- 
tion, of  this  purpose,  also,  they  found  themselves  subject  to  many 
inconveniences,  arising  partly  from  the  awkward  and  unmanage- 
able form  and  make  of  their  instruments,  and  partly  from  the  inar- 
tificial manner  in  which  they  applied  them. 

Terebrae,  and  terrebellae,  of  various  sorts,  figures  and  sizeis,  the 
cycliscos,  or  scalper  excisorius,  and  a  variety  of  modioli  were  in- 
vented, and  used  for  this  purpose,  figures  of  which  may  be  seen  in 
Vidus  Vidius's  Comment  on  Hippocrates  de  vuln.  capit.;  in  Peter 
Paaw  on  the  same;  in  Andreas  a  Cruce's  Officina;  in  Albucasis 
and  others. 

When  the  piece  of  bone  intended  to  be  removed  was  larger 
than  could  be  comprehended  within  the  modiolus  then  in  use,  and 
which  was  a  very  defective  instrument  in  many  respects,  the  ope- 
ration was  performed  by  means  of  terebrae;  which  operation  was 

g  "  In  lis  quze  usque  ad  cerebri  membranam  divisa  sunt,  si  sola  rima  sit, 
"  iisdem  radulis  utendum  ;  si  collisio  aliqiia  una  sit,  terebris  exscindere  colli- 
"  sum  oportet,  scalpris  adhibitis." 

Okibasius. 


108  INJURIES  OP  THE  HEAD 

still  more  coarse,  more  fatiguing,  and  more  hazardous  than  that  by 
the  mere  scalpra. 

The  piece  intended  to  be  taken  away  was  surrounded  with  per- 
forations made  at  small  distances''  from  each  other,  and  then  either 
the  scalper  excisorius  or  the  scalprum  lenticulatum  was  introduced, 
and,  by  means  of  repeated  strokes  with  a  heavy  mallet,  Avas  driven 
through  all  the  interspaces  between  each  perforation.  By  these 
means  the  portion  of  bone  so  surrounded  was  removed,  and  the 
dura  mater  was  laid  bare.  The  tediousness  which  must  attend 
the  making  so  many  perforations,  the  disturbance  given  to  the 
patiejit's  head,  as  well  by  the  terebra,  as  by  the  mallet  and  chizel, 

^  "  Ministri  juxta  assideant,  quorum  uinis  caput  Ixsi  contineat,  alter,  oppor- 
*'tuna  ministeria  faciat.  Aurium  foramina  lana  coacta  obturanda  sunt,  ne 
"sonitu  in  excisione  terreatur.  His  factis,  infigendus  calvarije  est  mucro  acutus 
"  terrebrje ;  qua  laesum  os  colorem  mutavit,  juxta  integrum ;  deinde  lente 
"  habena  terebram  convertere  debemus,  donee  inciso  ossi  mucro  insistat ;  ac 
"  turn  citatius  circumagere  oportet  habena  terebram  convertente,  donee  mu- 
"  cro  in  spatium  inter  duplex  os  descendat ;  ubi  autem  foramen  altius  adaetum 
"  sit  ultra  crassitudinem  spatii  inter  duplicem  testam  ossis  quod  perforatur, 
*'  turn  terebra  multo  eircumspectius  convertenda  est,  ne  repente  descendens 
"  cerebri  membranam  violet.  Cum  jam  terebra  adacta  fuerit,  ut  vel  con- 
"jectura  deprehendatur  totam  ossis  crassitudinem  esse  perforatam,  vel  per- 
"  parum  solids  sedis  infra  relictum,  tunc  is  qui  operatur,  altitudinem  de- 
"  gustet  demissa  tenuis  acus  obtusa  parte  ;  ac  si  quid  continuse  sedis  etiam 
"  reliquum  sit,  deprimendus  altius  terebrse  mucro  est,  eaque  lente  circu- 
*' macta,  solidum  os  perforandum.  Eadem  quoque  facienda  sunt  in  aliis 
"  foraminibus,  donee  rima  in  ambitu  perforata  sit.  Septa  vero  media  inter 
"foramina  satis  habent  spatii,  fere  quantum  specilli  augusti  aversa  pai's  est. 
"Factis  foraminibus,  turn  ad  excisionem,  qux  dicitur,  veniendum  est,  ut  ex- 
•'cisis  turn  foraminibus  turn  mediis,  laesa  ossa  removeantur." 

Oribasius. 
■  "  Modus  autem  perforationis  est,  ut  figas  unum  trypanorum  (terebarum) 
"super  OS  in  circuitu,  et  revolvas  ipsum  intra  manus  tuas,  donee  scias  quod 
*•  OS  terebratum  est ;  deinde  fiat  permutatio  ad  alium  locum  :  et  sic  permu- 
"tatio  fiat  usque  ad  ultimum  necessitatis.  Deinde  cum  alio  instrumento, 
"quod  dicitur  spatumen,  ab  uno  foramina  usque  ad  aliud  os  incidatur,"  &c. 

Bbunus  Cliir.  J\fag. 

"Pone  trypanum  supra  os  circa  scissuram,  ubi  vis  foramen  facere,  et  re- 
"  volve  ipsum  intra  manus  tuas  donee  penetret ;  deinde  muta  ipsum  ad  alium 
"locum,  et  sic  fae  tot  foramina,  quot  suffieiant;  deinde  pone  spatumen  in 
"  uno  foraminum,  et  levando  manum,  superius  incidatur  terminus,  qui  est 
"  inter  foramen  et  foramen,  et  fac  sic  donee  separatur  os  totum." 

Bhun.  Chir.  Part. 


FROM  EXTERNAL  VIOLENCE.  10.9 

the  hazards  of  wounding  the  membranes  of  the  brain,  and  the 
coarseness  and  unhandiness  of  the  whole  process,  are  too  obvious 
to  need  a  comment.' 

Of  this  most  of  them  were  sensible;  they  felt  the  inconve- 
niences, and  dreaded  the  danger  so  much,  as  to  run  into  great  ab- 
surdities, merely  to  avoid  them.  They  found  that  they  not  only 
wounded  the  dura  mater,  but  sometimes  the  brain  itself;  and 
therefore  had  recourse  to  such  precautions,  as  they  thought  most 
likely  to  prevent  these  evils.  By  some  we  are  advised,  not  to 
make  the  perforation  quite  through  the  bone,  but  to  endeavour  to 
leave  a  thin  lamina  of  it  entire.  By  others,  to  leave  the  piece, 
which  the  modiolus  or  terebra  had  surrounded,  adhering  to  the 
dura  mater,  to  be  cast  off  by  its  suppuration,  lest  the  hasty  de- 
tachment of  it  should  be  mischievous.'' 

'  "  Quod  vero  per  cycliscos  opus  administratur,  ne  id  quidem  omnino  vitio 
"  caret,  quum  quatiat  immodice  caput,  quod  potius  quietem  postulat." 

Galen, 
"  At  quae  per  terebellam  ratio  quidem  fungltur,  parum  tuta  est,  propterea 
"  quod  dum  audacius  earn  tractant,  duram  meningem  non  raro  violant." 

Galen. 
"  Ssepe  scalpros  pulsantes  adeo  ut  totum  cerebrum  permoveatur." 

Galen. 
"  Acuta  terebra  quamplurimas  angustas  perforationes,  cranii  fracturas  am- 
"bientes,  radioli  crassitudine  equidistahtes  formare  solent;  quod  vero  inter 
"foramina  residet,  aut  recti s,  aut  curvis  scalpris  malleolo  plumbeo  adactis 
*' rescindere  expedit.  Lenticulato  scalpro,  adacto  malleolo,  id  fieri  potest^ 
"  horridus  tameu  quidem  modus  est,  ac  in  opere  tardus." 

♦'  Scalpra  hsec  omnia  citra  malleoli  operam  nullius  momenti  sunt ;  moventur 
"  necessario  malleolo  adacto,  prxsertim  in  rimis,  quae  ad  diploidem  usque 
"  pertingunt  ;  excavant  totum  os,  ford  adhibita  percussione,  non  into  sed  in- 
"  commode." 

Andiieas  a  Cruce. 

"  Malleus  ad  percutiendum  lenticulatum  debet  esse  de  plumbo  ut  in  parva 
"  quantitate  magis  ponderet." 

GUIBO. 

"  Cavere  oportet  ut  in  terebellee  admotione,  ne  falleris,  verum  qua  parte 
"crassissimum  os  esse  visum  fuerit,  in  earn  semper  terebellam  admotam 
"  adigito." 

HiPPOCEAT. 

"  Saepe  accidit,  ut  terebree  repente  adactx,  ob  naturalem  perforatorum 
"  ossium-debilitatem,  vel  tenuitatem,  membranam  sauciarint." 

Oribasius. 
''  "Quod  si  statim  initio  vulneris  inflicti,.  curationi  adhibearis,  09  ad  mem- 


no  INJURIES  OF  THE  HEAI) 

The  cautions  laid  down  by  Hippocrates,  and  others,  concerning 
the  part  of  the  bone  whereon  to  fix  the  instrument,  and  the  great 
attention  which  they  admonish  the  operator  to  pay  to  its  execu- 
tion, all  proceed  from  the  same  fear.  For  the  same  reason,  or 
from  the  same  well-grounded  apprehension,  it  will  be  found  that 
many  of  the  best  practitioners  endeavoured  to  furnish  their  perfo- 
rating instruments  with  such  guards  or  defences  as  should  prevent 
them  from  going  too  deep.' 

In  Albucasis,  in  Andreas  a  Cruce,  and  many  others,  are  figures 
and  descriptions  of  modioli,  duabus,  tribus,  vel  quatuor  alis  mu- 

"  branam  usque  simul  et  semcl  exsclndere  non  oportet,  &c.  Prseterquam 
"  quod  aliud  subest  periculum,  si  stutim  ad  membraiiam  usque  auferas,  ne 
"  inter  operandum  membranam  lacdas.  Sed  inter  secandum  id  observaio,  ut 
"  postquum  eo  res  perducta,  ut  parum  absit  quin  unlversum  os  pertusum  sit, 
"  jamque  os  vacillare  incipit,  ab  ulteriore  sectione  abstineas,  ossique,  ut 
"  sponte  porro  secedat,  permittas.  Namque  ossi,  quod  sectum  est,  et  sine 
"  exsectione  relictum,  niliil  detrimentl  accidere  potest." 

"  Cum  itaque  terebrje  occurrit  usus,  si  statem  cui-ationi  adhibearis,  cavesis 
"  ne  ad  membranam  usque  penetrat,  verum  portio  ossis  tenuis  relinquenda." 

HiPPOCIlAT. 

1  "  Terebellis  autem  ipsis,  ut  mergi  non  possunt  supra  cuspidem,  nonnulli 
"  superciliiira  extans  efiiciunt." 

Galen. 

"  At  quia  dum  terebrum  hoc  circumagitur,  periculum  imminet  ne  mem- 
"  brana;  Isdantur,  ideo  nonnulli  quo  minus  aberrarent,  et  iioc  periculi  genus 
"  evitarent,  terebras  excogitarunt  qu?e  mergi  non  possunt,  et  ob  id  a  Greecis 
"  abaptista  dicuntur." 

Ajtdreas  a  Cruce. 

*'  Si  autem  os  forte  durem  est,  tunc  oportet  ut  pertbres  in  circuitu  ejus 

"  antequam  administres  incisoria  cum  terebris,  quae  nominantur  terebrae  non 

"  profundantes ;  et  non  nominantur  ita,  nisi  quoniam  ipsae  non  pertranseant 

"  terminum  ossis,  ad  illud  quod  est  post  ipsum,  propterea  quod  terebro  est 

"  extremitas  rotunda  super  illud,  quod  est  sub  capite  ejus  acuto,  similis  mar- 

"  gini,  et  circulus  parvulus  prohibet  submergi  et  pertransire  spissitudinem 

"  ossis.    Et  convenit  tibi,  ut  accipias  ex  istis  terebris  numerum  mukum,  quo- 

"  rum  unum  quodque  conveniat  quantitati  spissiludinis  ossis,  donee  prsesens 

"  sit  tibi  omni  cranio  terebrum,"  &c. 

Albucasis. 

"  Modiolus  fuit  veteribus  duplex,  estque  etiamnum  hodie  vulgaris,  turn  et 
"  qui  duplicem  liabet  orbem,  alterum  supra  alterum  extantem.  Hie  abuptis- 
"tos  Graecis;  facit  namque  orbis  sive  limbus  extans  ne  profundius  mergi 
"  queat.  Hunc  itaque  describit  Galenus  6.  meth.  cap.  6.  Quidem  autem  quo 
"  minus  aberrarent,  tales  terebellas  excogitarunt  quae  mergi  nequeant,  quas 
"  inde  abaptista  vocant.     Circomcurrit  enim  parum,  supra  terebellcC  super- 


PROM  EXTERNAL  VIOLENCE.  Ill 

niti,  of  those,  as  well  as  of  terebcllac,  called  abaptistai,  mespilata;, 
tortulatae,  &c.:  the  number  and  variety  of  these  are  very  large,  al- 
though they  are  all  formed  upon  the  same  principle,  and  all  calcu- 
lated for  the  same  purpose,  viz.  to  perforate  the  scull  without 
wounding  the  membrane  underneath.  But  whoever  will  consider 
the  very  different  thickness  of  different  sculls,  and  of  different 
parts  of  the  same  scull,  and  at  the  same  time  reflect  on  the  ex- 
treme awkwardness  of  all  these  instruments,  will  immediately  see 
how  very  little  dependence  is  to  be  laid  on  such  defences,  and 
how  mischievous  the  use  of  them  must  very  frequently  have 
proved.  In  short,  an  attentive  consideration  of  what  our  remote 
ancestors  have  delivered  down  to  us  on  this  subject  may  satisfy 
us,  that  their  observations  on  the  appearances  and  symptoms  of 
the  ills  attending  this  kind  of  mischief,  that  is,  fractures  of  th€ 
cranium,  were  in  general  extremely  just  and  true,  perhaps  more 
so  than  those  of  many  moderns;  that  their  curative  intention,  or 
method  of  aiming  at  the  relief  or  cure  of  such  ills,  was  rational 
and  just;  but  that  the  instrumental  part  of  their  art  was  so  defi- 
cient, so  awkward,  and  so  unhandy,  that  thiey  were  thereby  not 
only  in  general  prevented  from  accomplishing  the  good  they  in- 
tended, but  were  not  infrequently  driven  into  almost  unavoidable 
mischief. 

Reduction  of  the  number  of  instruments  to  be  used  in  an  ope- 
ration, and  an  extreme  simplicity  and  plainness  in  those  which 
may  be  required,  are  a  part  of  the  merit  of  modern  surgery. 

The  majority  of  the  instruments,  with  which  our  ancestors  per- 
forated the  cranium,  were  contrived  to  make  way  for  the  admis- 
sion of  other  instruments;  such  as  the  scalper  excisorius,  the  cy- 
cliscos,  the  scalprum  lenticulatum,  &c.  with  which  they  removed 
a  portion  of  bone.     Even  the  modioli,  which  were  used  by  them, 

"  cilium  circulus  alius  parvus.  Sane  expedit  complures  id  genus  ad  manum 
"  habere,  ob  quamcunque  cranii  crassitudinem ;  nam  crassiori  longior  conve- 
"  nit  terebra,  tenuiori  brevior,"  &c. 

Pet.  Paaw  in  Hippocbat. 

"  Si  autera  validum  fuerit  os,  prius  illud  terebellis  abaptistis  vacatis  per- 
"  foratur.  Ejusmodi  vero  sunt  quse  paulo  supra  acumen  cuspidis  eminentias 
"  habent,  impedientes  ne  ad  cerebriusque  membranam  demergi  possint.*' 

Paul.  Mgiitbt. 


l\2  IN.>L'RIES  OP  THE  HEAD 

were  so  small  in  the  diameter  of  the  saw,  as  to  take  away  a  very 
small  piece  at  each  application;  which  circumstance  necessarily 
lessened  the  benefit  which  might  be  expected  from  the  use  of  it, 
and  rendered  its  repetition  more  frequently  necessary  than  it  need- 
ed to  have  been,  if  it  had  been  made  larger. 

Instead  therefore  of  that  strange  variety  and  multiplicity  of  in- 
struments, which  I  have  already  mentioned  to  have  been  used  by 
them,  we  now  require  only  a  trephine  of  such  a  side  as  to  remove 
a  sufficient  quantity  of  bone  at  once,  and  an  elevator;  or  perhaps, 
now  and  then  a  pair  of  forceps.  These  are  all  we  ever  can  want; 
and  these  may  be  so  made,  as  to  be  manageable  by  the  hand  of 
any  man  of  common  judgment,  with  great  ease  to  himself,  with 
very  little  fatigue  and  no  hazard  to  the  patient.  With  these  we 
can  make  as  large  or  as  small  an  opening  in  the  scull  as  we  please; 
either  for  the  relief  of  the  dura  mater,  for  the  discharge  of  blood  or 
matter,  or  for  the  elevation  of  depressed  or  extraction  of  loose 
pieces  of  bone,  and  that  without  disturbing  the  patient  greatly, 
or  incurring  any  risk  of  wounding  the  brain  or  its  membranes."" 

I  have  already  said,  that  what  are  called  the  principal  and  di- 
agnostic signs  of  a  fractured  scull  are  by  no  means  to  be  depend- 
ed on,  as  indicating  such  mischief  to  exist;  it  can  therefore  be 
hardly  necessary  to  observe,  that  what  are  called  the  uncertain 
signs  require  our  regard  still  less.  These  have  been  mentioned 
by  many  writers,  who  have  copied  each  other;  such  are,  the  hold'- 
ing  a  silk  or  horse-hair  tight  between  the  grinding  teeth  and  the 
hand,  and  the  making  it  vibrate  by  striking  on  it;  the  biting  an 

"  It  has  been  customary  to  make  the  handle  of  the  ti'ephine  of  iron,  and  to 
form  the  extremity  of  such  handle  in  such  manner,  as  to  make  it  serve  the 
purpose  of  an  elevator ;  thus  combining',  as  it  were,  two  instruments  in  one. 
This,  I  think,  is  a  great  fault ;  such  iron  handle  adds  considerably  to  the 
weight  of  the  instrument,  and  that  in  a  wrong  part  of  it ;  and  thereby  renders 
it  less  manageable.  The  handle  of  this  instrument  should  be  made  of  light 
wood,  not  too  long,  and  of  an  octangular  figure.  "Whoever  will  try  the  same 
instruments,  thus  differently  made,  will,  I  think,  be  immediately  sensible  of 
the  preference  due  to  the  lighter  handle.  It  is  almost  impossible  for  the  han- 
dle of  an  instrument,  whose  point  or  extremity  is  to  be  worked  with,  to  be  too 
light.  It  is  no  uncommon  thing  to  see  couching  needles,  and  instruments  of 
like  kind,  laden  with  heavy  bone  handles  ;  the  Inconvenience  of  ^hich  is  too 
obvious  to  mention. 


t^  fi'on/-Fa<ff   JJ2  VchI 


FROM  EXTERNAL  VIOLENCE.  113 

hard  body,  and  attending  to  the  pain  produced  by  such  action; 
with  several  other  of  like  sort;  which,  not  to  mention  that  they 
imply  the  patient  to  be  sensible  and  intelligent,  arc  so  truly  equi- 
vocal as  to  deserve  no  notice." 

All  considerations,  also,  which  are  drawn  from  the  manner  in 
which  the  violence  was  given  or  received,  from  the  weight  or 
kind  of  weapon  or  body  inflicting  it,  from  the  force  of  the  blow, 
the  heightof  the  fall,  &c.  are  all  equally  fallacious;  for  every  body 
knows,  that  very  terrible  symptoms  and  consequences  are  some= 
times  produced  by  accidents  seemingly  slight;  and,  on  the  con- 
trary, that  people  escape  unhurt,  from  what  might  reasonably 
have  been  expected  to  have  proved  prejudicial  to  them.  In  short, 
nothing  but  the  sight  and  touch  are  to  be  at  all  depended  upon. 

If  the  integuments  be  not  wounded,  or  if  the  wound  made  in 
them  be  so  small  as  not  to  admit  a  proper  examination  of  the  bone, 
and  the  circumstances  of  the  case  be  such  as  render  such  inquiry 
necessary,  a  portion  of  the  scalp  should  be  removed.  The  man- 
ner of  doing  this  has  formerly  been  the  occasion  of  much  differ- 
ence of  opinion;  but  there  can  be  no  doubt  about  the  greater  pro- 
priety of  removing  a  piece  of  the  scalp  for  this  purpose,  by  an  in- 
cision in  a  circular  form,  it  being  that  form  which  must  afford  the 
clearest  view.  If  there  be  no  wound,  the  point  stricken  should  be 
made  the  centre  of  the  incision;  if  there  be  a  wound,  such  wound 
should  be  made  the  centre  of  the  piece  to  be  removed;  and  such 
piece  should  always  be  of  size  sufficient  to  render  the  application 
of  the  trephine  easy."  P 

"  "  Item  percutiatur  caput  cum  levl  bacculo  sicco,  de  salice  aut  de  pincj 
"  et  pone  aurem  tuam  apud  caput ;  et  si  sanum  est,  tunc  audies  soniiin  sanum  ; 
"  sifractum  aut  scissum,  audies  sonum  mutum."  LANruAsc. 

"  It  may  perliaps  be  remarked,  that,  through  the  whole  of  this'treatise,  when- 
ever I  have  occasion  to  speak  of  the  operation  of  perforating  the  sculi,  I  men- 
tion the  trephine  only,  and  take  no  notice  of  tiie  trepan,  the  instrument  used 
by  most  of  our  immediate  fathers,  and  stili  in  use  through  ahuost  all  France ; 
my  reason  is,  that  the  latter  is  an  unmanageable  one,  and  liable  to  most  of  the 
hazard  .and  inconvenience  attending  the  terebrse  and  terebellK. 

P  In  a  former  part  of  this  work,  Mr.  Po"  has  strongly  expressed  his  dis^ 
approbation  of  removing  any  part  of  the  scalp  unnecessarilv  On  the  same 
principle,  if  any  doubt  exists  of  finding  such  mischief  underneath  the  scalp 

VOL.  I.  '  P 


114  INJURIES  OF  THE  HEAD 

If  the  scalp  be  wounded,  and  the  wound  be  large  enough  to 
render  the  fracture  visible,  the  course  of  that  must  be  the  opera- 
tor's direction  in  making  his  incision;  and  if  the  skin  be  much 
torn  and  bruised,  or  spoiled,  it  will  generally  be  found  adviseable 
to  take  away  all  that  is  spoiled  at  once;  as  the  removal  of  it  will 
add  very  little  to  the  patient's  pain,  or  the  length  of  the  cure;  and 
the  leaving  it  in  this  state  may  be  attended  with  great  future  in- 
convenience. 

Scalping  (as  it  is  called)  should  always  be  executed  with  a 
knife,  and  that  knife  should  be  so  held  as  to  cut  through  the  skin 
and  pericranium  in  a  perpendicular  manner,  down  to  the  bone  at 
once,  that  the  size  of  the  bare  bone  may  be  fully  equal  to  that  of 
the  wound  in  the  scalp. 

It  is  hardly  necessary  to  insert  a  caution  against  pressing  hard 
with  the  scalping  knife,  in  the  case  of  large  fractures,  attended  ei- 
ther with  great  separation  of  the  broken  edges,  or  with  loose  pieces, 
the  danger  is  so  obvious.  And  it  is  also  as  obvious,  that  there  can 
be  but  one  method  of  avoiding  such  hazard;  viz.  by  removing  the 
scalp  from,  or  rather  making  the  incision  in  apart  beyond  the  frac- 
ture, and  where  the  bone  is  firm  and  stable.  By  these  means, 
not  only  the  risk  of  hurting  the  membranes  and  brain  will  be 
avoided,  but  the  whole  mischief  will  be  more  fairly  and  clearly 
brought  into  view;  a  thing  which  sooner  or  later  must  be  done,  and 
is  always  best  done  at  first.  No  part  of  the  scalp  should  be  wan- 
tonly or  unnecessarily  cut  away:  but  it  should  always  be  remem- 
bered, that  this  operation  is,  and  should  be  performed,  with  in- 
tention to  bring,  if  possible,  the  whole  fracture  into  sight;  and 
that  whatever  falls  short  of  fulfilling  such  intention  (if  practicable) 
is  wrong,  not  only,  as  it  does  not  immediately  answer  the  purpose 
for  which  it  is  intended,  but  it  generally  puts  the  patient  under  a 
necessity  of  undergoing  the  same  pain  and  trouble  a  second 
time. 

When  the  cranium  is  laid  bare,  it  may  not  be  improper  to  re- 

as  will  make  removal  of  bone  necessary,  I  should  recommend  to  make  a  cru- 
cial incision,  rather  than  at  once  to  take  away  any  part  of  the  scalji.  By  a 
crucial  incision,  a  satisfactory  examination  may  be  made  ;  and  if  it  be  found 
unnecessary  to  proceed  further,  the  scalp  may  be  laid  down  again,  and  pre- 
served :  if  found  necessary,  it  may  be  easily  removed.        E. 


FROM  EXTERNAL  VIOLENCE.  115 

mark,  that  writers  in  general  have  cautioned  us  to  beware  of 
mistaking  either  a  suture,  or  the  impression  of  a  vessel  on  the 
surface  of  the  bone,  for  a  fracture:  I  say  tha't  they  have  in  general 
cautioned  us  not  to  mistake  one  of  these  for  the  other,  but  have 
not  informed  us  of  the  mark  by  which  we  may  be  enabled  to 
make  the  necessary  distinction,  although  such  mark  is  almost 
constant  and  invariable.  From  the  track  of  a  fracture,  or  fissure, 
the  pericranium  is  always  found  loose  and  detached;  whereas  to 
the  arterial  sulcus,  and  to  the  uninjured  suture,  it  is  ahvays 
adherent;  besides  which,  the  edges  of  a  fracture  will  always  be 
found  rough  to  the  probe  or  finger,  and  the  sulcus  always  smooth; 
not  to  add,  that  the  disposition  of  the  sutures  is  pretty  certain, 
and  their  appearance  in  general  not  extremely  like  to  that  of  a 
fracture. 

When  the  scalp  is  much  bruised,  or  wounded,  such  wound  or 
bruise  points  out  the  place  from  whence  the  piece  should  be  re- 
moved, in  order  to  examine  the  bone;  and,  even  although  no  frac- 
ture should  be  found,  is  an  authority  and  vindication  of  such 
operation,  especially  if  the  general  symptoms  were  at  all  urgent; 
such  symptoms  implying  mischief  somewhere,  and  such  external 
mark  rendering  it  clear,  where  the  external  violence  causing  such 
mischief  was  inflicted.  But  all  the  ancient,  and  many  of  the 
modern  writers,  speak  of  a  particular  kind  of  fracture,  in  which 
the  scalp  covering  it  is  perfectly  fair  and  uninjured,  and  this  they 
call  a  contra-fissure.  By  the  general  account  it  is  pretty  clear, 
that  the  majority  of  those  who  have  spoken  of  this  kind  of  frac- 
ture have  supposed  that  the  breach  made  in  the  bone  was  most 
frequently  in  the  part  of  the  cranium  diametrically  opposite  to 
that  which  received  the  blow;  this  the  term  contra-fissure  implies, 
and  this  they  most  certainly  do  in  general  mean  should  be  under- 
stood by  it,  as  appears  by  their  directing  us  to  examine  and  to 
remove  the  opposite  part  of  the  scalp,  if  no  mischief  be  found 
under  the  part  stricken,  and  the  patient  labours  under  what  are 
called  the  symptoms  of  a  fractured  scull. 

If  the  symptoms  of  a  fractured  cranium  were  certain,  and  to  be 
depended  upon,  this  accidental  circumstance,  of  a  breach  in  the 
bone  having  been  now  and  then  found  in  a  distant,  or  ev'^en  in  the 
opposite  part,  might  be  an  inducement  to  look  for  such  mischief 


116  INJURIES  OF  THE  HEAD 

there,  ulien  it  is  not  found  uncicr  the  part  stricken.  A  fracture, 
we  might  then  say,  there  is  somewhere;  and  it  having  in  some 
instances  been  found  in  t-he  opposite  part  of  the  head,  it  might  be 
i'ight  to  look  for  it  there.  But  as  what  generally  pass  for,  and  are 
called  the  symptoms  of  a  fracture;!  scull,  are  by  no  means  to  be 
depended  upon,  as  indicating  such  complaint  to  exist  any  where, 
as  they  are  producible  by  concussion,  by  extravasation,  by  contu- 
sion, &c.  and  are  frequently  found  ivhere  the  scull  is  entire  and 
unhurt,  they  cannot  be  deemed  a  sufficient  authority  for  removing 
the  scalp  where  no  apparent  mark  of  violence  is  left.  The  smallest 
degree  of  wound  or  bruise  will,  in  cases  where  the  symptoms  are 
urgent,  vindicate  the  removal  of  scalp  from  such  part;  but  where 
there  is  no  local  indication  where  to  operate,  I  cannot  see  any 
vindicable  reason  for  operating  at  all.'' 

The  chirurgical  intention  in  perforating  the  scull,  in  the  case  of 
simple  undepressed  fractures,  is,  as  I  have  already  observed,  either 
to  give  immediate  discharge  to  a  fluid  supposed  to  be  extravasated 
between  the  cranium  and  membranes  of  the  brain;  or  to  obviate 
and  prevent  such  ills,  as  may  most  probably  be  expected  to  arise 
from  the  conajsion  causing  the  fracture;  or  to  let  out  matter  already 
formed  iu  consequence  of  the  inflammation  following  such  con-, 
tusion. 

In  each  of  these  it  is  most  probable,  that  the  mischief,  be  it 
w'hich  it  may,  either  is  or  will  be  seated  principally  under  the 
track  of  the  fracture;  and  therefore,  whenever  the  trephine  is 
applied  for  either  or  any  of  these  purposes,  it  ought  always  to  be 
set  on  in  such  manner  as  that  the  fracture  should,  if  possible, 

1  Morgagnij  in  his  book  lieCausis  et  Sedibiis,  lias  veiy  justly  observed, 
"  That  if  by  contra-fissiire  v/as  meant  a  breach  in  that  part  of  the  cranium 
"  which  is  diametrically  opposite  to  the  part  wounded  or  bruised,  (as  some 
"  have  amrmed,)  there  could  be  none  of  that  dinicuUy  which  they  all  allow 
"  of  finding-,  or  that  frequent  disappointment  in  not  finding  it  at  all,  since  an 
"  inquiry  into  such  opposite  {)art  must  always  have  led  to  the  discovery.  So 
"  that,  instead  of  the  leim  opposite,  that  of  nnothcT  p-Art  of  the  cranium  ought 
"  to  have  been  used."  And  then  t!ie  whole  of  this,  wljich  has  puzzled  so 
many,  will  amount'to  no  more  than  wliat  every  practitioner  rnu.st  kijow,  wiiich 
is,  that  we  frequently  find,  in  cases  of  great  violence,  that  the  scull  has  been 
-broken  in  a  i)lace  very  distant  from  that  whicli  received  the  blow,  and  which 
we  are  not  led  to  the  knowledge  of  by  any  apparent  external  mark. 


FROM  EXTERNAL  VIOLENCE.  117 

traverse  the  circle  described  by  ihe  saw,  or,  at  least,  so  that  tlie 
instrument  might  always  comprehend  the  fracture  within  it. 

I  am  aware  that  the  direction  given  by  most  of  the  old  writers 
on  this  subject  is  very  different  from  what  I  have  mentioned;  but 
the  instruments  with  which  they  operated  were  so  different  from 
ours,  and  the  advantages  arising  from  the  comprehension  of  the 
fracture  within  the  trephine  are  so  great,  and  so  manifest,  that 
I  must  take  the  liberty  of  inculcating  a  constant  attention  to  it,  as 
to  a  circumstance  from  which  great  advantages  are  derivable. 

The  saw  or  crown  of  the  trephine  should  never  be  too  small, 
especially  if  the  patient  be  full  grown;  a  circumstance  which 
I  thought  it  right  to  mention,  because  the  instrument-makers  are 
very  apt  to  make  them  so,"^ 

The  number  of  perforations  which  it  may  be  necessary  to  make, 
can  only  be  determined  by  the  nature  of  each  individual  case. 

If  the  operation  be  performed  on  account  of  such  symptoms  as 
seem  to  indicate  a  bloody  extravasation,  and  so  free  a  discharge 
is  produced  by  one  opening,  as  alleviates  or  removes  the  symp- 
toms, that  one  may  be  all  that  may  be  necessary;  but  if  the  first 
perforation  only  discovers  the  disease,  and  is  not  followed  by  such 
discharge  as  relieves  or  removes  the  symptoms,  the  operation 
ought  to  be  repeated  again  and  again. 

If  there  be  no  symptoms  of  extravasation,  and  the  instrument 
has  been  applied  in  a  preventative  sense  merely,  the  length  of  the 
fracture  must  determine  the  number;  one  or  two  only  may  be 
made  at  first;  and  it  may  be  right  to  wait  for  farther  direction 
from  future  circumstances.  The  circumstances  which  may  ren- 
der a  repetition  of  the  operation  necessary  are,  accession  or  in- 
crease of  fever;  large  discharge  of  matter,  or  lodgement  of  the 
,5ame  fluid;  inflammatory  tension  of  that  part  of  the  dura  mater 

"f  The  best;  practiliorcrs  have,  at  times,  found  themselves  ;iecesr,it:itcd  to 
apply  the  instrument  repeatedly  in  the  same  case,  in  order  to  remove  a  con- 
siderable quantity  of  bone;  and  among  the  writers  on  this  subject,  are  frequent 
relations  of  sucli  facts.  The  practice  is  undoubtedly  just  and  rii^ht;  but  I 
cannot  help  thinl^.ing,  from  what  I  have  seen  of  the  perforating-  instruments 
of  many  of  our  predecessors,  tliat  a  part  of  tlieir  trouble,  and  of  the  fatigue  of 
their  patients  in  such  cases,  might  have  been  much  lessened,  hud  the  circle 
of  liieir  saw  been  larger,  Tlu'  aclvantifgr;  rf  a  lai-jv"  ^:;:"(-'o  is  great ;  the  incon- 
vcr,Icni:e  in'iagir/un-. 


118  INJURIES  OF  THE  HEAD 

which  has  ah'eady  been  denuded,  &c.  Directions  to  be  given  by 
a  writer  can,  on  this  subject,  be  only  and  truly  general;  all  the 
rest  nnist  be  left  to  the  judgment  of  the  surgeon,  which  judgment 
must  be  formed  from  the  peculiar  nature  of  each  individual  case. 

When  the  operation  has  not  been  performed  as  a  preventative, 
but  to  give  discharge  to  that  matter  which  a  symptomatic  fever  in- 
dicates to  have  been  formed,  the  quantity  of  such  fluid,  the  ex- 
tent of  the  secession  of  the  dura  mater,  and  the  state  of  that  mem- 
brane, must  determine  the  conduct  of  the  operator.  The  only 
chance  of  relief  is,  from  laying  bare  a  large  portion  of  it,  that  the 
discharge  may  be  as  free,  and  the  confinement  as  little  as  possi- 
ble; nothing  but  this  can  do  good;  the  space  of  time  in  which  it 
may  prove  beneficial  is  very  short,  that  once  elapsed  is  absolutely 
irrecoverable;  and  the  necessary  operation  for  obtaining  such  end 
may  full  as  well  be  totally  neglected,  as  done  by  halves,  or  too 
late. 

The  extent  of  the  injured  and  separated  dura  mater,  and  con- 
sequently of  the  vacuity  for  the  formation  and  lodgement  of  mat- 
ter, is  a  thing  of  so  much  consequence,  that  it  is  to  be  wished  we 
were  able  to  discover  it  with  more  precision  and  clearness  than 
we  seem  to  be  able  to  do.  It  is  the  greatest  circumstance  of  ha- 
zard to  the  patient,  and  of  direction  to  the  surgeon.  It  is  that 
which,  if  undiscovered  or  neglected,  must  destroy  the  former,  and 
that,  which  when  discoverable,  and  attended  to  by  the  latter,  is 
not  only  his  information,  but  his  vindication. 

The  concealment  of  the  dura  mater  within  the  cranium  is  one 
great  cause  of  this  great  obscurity.  This  necessarily  prevents  us 
from  knowing  the  true  state  of  that  membrane,  as  much  and  as 
certainly  as  it  is  to  be  wished  we  could;  but  still  I  cannot  help 
thinking,  that  there  are  some  circumstances  and  appearances,  as 
well  before  perforation  as  after,  which,  if  carefully  and  duly  at- 
tended to,  may  throw  some  light  on  this  obscure  part  of  surgery. 
For  example;  if,  upon  dividing  the  scalp,  the  pei'lcranium  is  found 
to  be  altered,  and  perfectly  separated  from  the  scull,  to  which  it 
ought  naturally  to  adhere;  or  if,  some  few  days  after  scalping,  (as 
it  is  called,)  the  edges  of  such  wound  spontaneously  quit  their 
adhesion  to  the  bone  all  round,  io  some  distance,  and  instead  of 
being  firm,  florid,  and  healthy,  become  loose,  tawny,  and  flabby; 


PROM  EXTERNAL  VIOLENCE.  119 

or  if  the  scull,  upon  being  denuded,  is  plainly  of  a  colour  different 
from  that  of  a  healthy  sound  bone,  with  a  healthy  sound  mem- 
brane under  it;  or  if  such  bone,  after  having  been  either  accident- 
ally or  designedly  laid  bare,  undergoes  such  morbid  change  of 
aspect,  and  the  patient  is  at  the  same  time  restless  and  feverish, 
with  tensive  pain  in  the  head,  and  irregularly  returning  fits  of 
heat  and  chilliness;  I  think  that  we  may  most  reasonably  presume, 
that  the  dura  mater  in  such  patient  is  inflamed;  and  that  the  seat  of 
such  inflammation  is  under  such  bare  and  altered  part  of  the  scull. 

This  presumption,  as  I  have  just  observed,  may  take  place  be- 
fore perforation;  but,  if  added  to  these  circumstances,  which  ap- 
pear before  the  operation,  vvc  find  upon  perforating  that  the 
membrane  is  inflamed,  detached,  altered  from  its  natural  texture 
and  brightness,  or  smeared  over  with  matter,  the  case  is  then 
clear,  as  to  its  nature;  and  it  is  as  clear,  that  nothing  but  the  re- 
moval of  a  considerable  portion  of  the  scull  can  either  give  room 
for  the  inflammatory  tension  of  the  membrane,  or  make  way  for 
the  discharge  of  matter  generated  on  its  surface;  the  two  circum- 
stances on  which  the  well-being  of  the  patient  depends,  the  two 
intentions  which  must  be  fulfilled,  and  which  nothing  but  free 
perforation  can  enable  us  to  fulfil.  Whatever  degree  of  hazard 
may  be  supposed  to  be  incurred,  by  having  exposed  the  dura  ma- 
ter to  the  air,  cannot  be  increased  by  the  mere  comparative  size 
of  the  opening;  and  if  we  may  be  allowed  to  expose  our  patients 
to  any  risk  at  all,  it  can  only  be  upon  a  supposition  that  a  greater 
degree  of  good  may  be  deducible  from  it. 

It  sometimes  happens,  that  one  of  the  bones  of  the  scull  is 
cracked,  and  the  dura  mater  underneath  such  crack  is  so  injured 
as  to  become  inflamed,  and  in  process  of  time  to  suppurate;  but 
there  being  no  early  or  immediate  symptom  of  such  mischief,  and 
the  scalp  being  neither  wounded  nor  bruised  in  such  manner  or 
degree  as  to  authorise  the  removal  of  the  scalp,  the  true  nature  of 
the  case  is  not  known,  nor  the  impending  mischief  attended  to, 
until  the  symptoms  of  inflammation  begin  to  appear.  In  tliis  si- 
tuation, after  an  uncertain  number  of  da^s,  (sometimes  more, 
sometimes  less,)  the. patient  finds  himself  out  of  order,  is  restless, 
does  not  get  natural  or  quiet  sleep,  is  flushed  and  chilly  by  turns, 
feels  pain  of  the  dull  tensive  kind  ail  over  his  head,  but  particu- 


120  INJURIES  OF  THE  HEAD 

larly  In  the  part  where  the  blow  was  inflicted.  Soon  after  he 
has  got  into  this  state,  the  part  so  pained  becomes  in  some  degree 
tumid,  the  febrile  symptoms  advancing  notwithstanding  every  in- 
ternal assistance.  If  in  these  circumstances  the  tumid  part  of  the 
scalp  be  divided,  and  the  cranium  be  found  bare,  (the  pericra- 
nium having  spontaneously  quitted  its  adhesion,)  whether  it  be 
broken  or  not,  mischief  is  certainly  forming''  underneath  it,  and 
the  one  remedy  is  perforation. 

It  also  sometimes  happens  that  a  fine  capillary  fissure  runs  or  is 
continued  under  an  undivided  part  of  the  scalp,  from  the  extremity 
of  a  fracture  to  a  distance  greater  or  less;  or,  in  other  words,  the 
fracture  in  its  track,  from  being  open  and  apparent,  becomes 
capillary,  and  is  either  not  seen  or  not  attended  to.  If  the  dura 
mater,  under  such  fissure,  does  not  become  inflamed,  it  may  possi- 
bly never  give  any  trouble;  but  if  it  does  become  inflamed,  .and 
suppurate,  the  scalp  covering  such  fissure  will,  at  +he  end  of  some 
days,  swell,  and  become  tender  to  the  touch;  the  pericranium 
will,  by  separating  from  the  bone,  form  a  sinus  along  the  track  of 
the  fissure,  a  discharge  of  gleet  will  be  made  from  it  upon  pres- 
sure, and  the  division  of  it  will  display  the  breach  in  the  bone. 

Notwithstanding  the  fracture  from  which  this  fissure  is  con= 
tinned  be  large  and  open,  and  the  trephine  may  also  have  been 
more  than  once  used  to  such  fracture,  yet,  when  the  appearances 
are  such  as  I  have  related,  if  the  patient  be  not  entirely  free  from 
all  general  symptoms  of  inflammatory  mischief,  it  may  be  de- 
pended upon,  ihdt  the  membrane  under  the  fissure  is  diseased; 
and  if  a  convenient  opening  be  not  made  upon  the  part  aggrieved, 
bad  consequences  will  follow,  notwithstanding  all  that  may  have 
been  done  to  the  more  visible  and  open  part  of  the  fracture;  a  very 
strong  and  convincing  pi'oof  of  the  nature  of  a  local  inflammation 
of  the  dura  mater,  as  well  as  of  the  most  proper  method  of  treating 
such  disorder. 

In  cases  of  great  violence  offered  to  the  head,  whether  the  scull 

'  "  Osslum  vima  oculta  interdum  non  ante  septimum  diem,  interdum  nou 
"  ante  decimum  quartum,  interdum  serius  se  ostendit ;  tum  caro  ab  osse  re- 
"  cedit;  tumque  os  lividum  apparet ;  dolores  item  ichorum  diffluentium  es- 
"  citantur;  atque  hsc  difficulter  remediis  ceduut.'^  HirrocEAX- 


FROM  EXTERNAL  VIOLENCE.  121 

be  broken  or  not,  it  sometimes  happens,  more  particularly  in  young 
subjects,  that  we  find  a  suture  considerably  disjoined;  in  which 
circumstance  I  do  not  remember  ever  to  have  seen  one  single  in- 
stance of  a  recovery.* 

I  cannot  take  leave  of  this  subject  without  reminding  the  young 
practitioner,  that  although  it  be  impossible  for  any  one,  in  the 
case  of  a  highly  inflamed  or  suppurating  dura  mater,  to  get  well 
without  perforation  of  the  scull,  yet  that  operation  must  be 
considered  only  as  one  absolutely  necessary  part  of  the  pro- 
cess toward  obtaining  a  cure;  and  that  phlebotomy,  gentle  eva- 
cuations per  anum,  proper  febrifuge  remedies,  and  a  strict  low 
diet  and  regimen,  will  be  full  as  necessary  after  such  operation  as 
before  it.  The  removal  of  a  piece  of  bone  takes  off  some  pressure 
from  the  tense  and  inflamed  membrane,  frees  it  in  some  degree 
from  its  confinement,  and  gives  discharge  to  matter  and  gleet;  but 
it  does  no  more;  and  every  means  which  can  serve  to  appease  the 
febrile  heat,  to  lessen  the  velocity  of  the  circulating  fluids,  to 
render  the  skin  perspirable,  and  the  patient  cool  and  easy,  are  fuH 
as  necessary  after  as  before  such  operation. 


CASE  XVII. 

SIMPLE  FRACTURE. 

A  PRINCIPAL  overseer  of  one  of  the  great  roads  near  to  this 
town  was  thrown  down  with  great  violence,  while  he  was  giving 
directions  to  the  labourers.  He  fell  with  his  forehead  against  a 
sharp  stone,  and  lay  senseless  for  a  few  minutes,  but  soon  re- 
covered himself,  and  walked  home.  The  stone  had  made  a  con- 
siderable wound,  the  lips  of  which  were  so  torn  and  bruised,  that 
the  surgeon  who  first  saw  him  cut  them  away,  and  by  that  means 
detected  a  fracture,  or  rather  a  fissure,  of  about  an  inch  and  a  half 

«  "  Repentina  suturarum  disjunctio,  si  causam  attendas,  sine  aliqua  cerebri 
"  concussione  esse  non  potest :  si  effectum,  non  sine  violenta  crasse  meningis, 
"  illuc  magis  adhserentis  distractione,  ac  annectentium  sibrillarum  ac  vascu- 
"lorum  laceratione."  &c, 

MoHPAGKi  De  Causis  et  Sed: 
VOL.  I.  Q 


INJURIES  OP  THE  HEAD 

or  two  inches  in  length,  on  the  upper  or  middle  part  of  the  os  tion- 
tale.  The  man  had  neither  sickness,  giddiness,  vomiting,  fever, 
nor  any  other  bad  symptom  for  several  days;  on  which  account 
nothing  was  done  to  the  fracture,  which  was  dressed  with  dry  lint 
only.  He  was  twice  let  blood,  and  kept  to  a  low  cool  regimen. 
At  the  end  of  seven  days,  he  found  himself  so  well,  that  he  was 
desirous  of  going  out;  but  that  not  being  permitted,  he  stayed  at 
home,  and  took  great  care  of  himself.  On  the  eleventh  day  he 
found  himself  out  of  order,  said  that  his  head  ached,  that  his 
stomach  was  not  right,  and  ate  no  dinner.  The  following  night 
he  got  but  little  rest.  On  the  thirteenth  day,  having  passed  very 
unquietly  the  preceding  night,  he  did  not  rise;  and  when  his  sur- 
geon came  to  dress  him,  finding  him  feverish,  he  let  him  blood,  and 
gave  him  a  lenient  cathartic.  In  the  space  of  two  days  more  all 
his  symptoms  were  exasperated;  his  head-ach  was  great  and  con- 
stant, his  fever  high,  he  got  no  sleep  at  all,  the  edges  of  the  wound- 
ed scalp  became  foul,  loose,  and  spongy,  and  his  forehead  and 
visage  were  attacked  with  an  inflammatory  swelling  of  the  erysi- 
pelatous kind.  On  the  sixteenth  day  he  had  a  severe  rigor,  and 
was  somewhat  delirious,  and  his  eyes  became  so  tumefied  that  he 
could  not  open  them.  In  this  state  I  found  him.  Being  informed 
of  what  I  have  here  related,  and  having  examined  the  bare 
cranium,  I  could  not  hesitate  to  say,  that  I  apprehended  his  com- 
plaint proceeded  from  the  formation  and  confinement  of  matter 
■within  the  scull;  and  that  the  little  chance  the  man  had  must  be 
from  immediate  perforation  in  the  track  of  the  fissure. 

The  operation  was  performed,  and  the  dura  mater  found  covered 
with  matter.  He  was  dressed  lightly,  and  lost  twelve  ounces  of 
blood. 

The  next  day  I  was  informed  that  he  was  very  rational,  but  his 
fever  unremitting,  and  that  he  got  no  sleep.  On  the  nineteenth 
day  I  saw  him  again,  along  with  the  late  Mr.  Bethune;  the  dis- 
charge from  within  the  scull  was  large,  and  the  bare  bone  and 
wounded  scalp  looked  very  ill;  all  his  other  symptoms  much  the 
same. 

On  the  twenty-first  I  was  sent  for  again.  He  was  now  deliri- 
ous in  a  high  degree,  paralytic  in  one  arm  and  leg,  and  frequently 
convulsed  in  the  other;  the  discharge  was  large  and  remarkably 


PROM  EXTERNAL  VIOLENCE.  123 

offensive,  his  tongue  black,  the  skin  of  his  body  burning  hot  and 
diy,  that  of  his  extremities  cold  and  moist,  and  I  suppose  I  need 
not  tell  the  reader  what  happened  that  night. 


CASE  xviir. 

A  YOUNG  man  playing  at  cudgels  in  Moorfields  received  a  stroke 
on  his  forehead;  it  did  not  seem  either  to  himself  or  the  specta- 
tors to  have  been  a  severe  one;  but  as  it  produced  blood,  it  was 
deemed  by  the  laws  of  the  game  a  broken  head,  and  he  was 
obliged  to  yield  to  his  antagonist. 

As  it  gave  him  no  trouble,  he  took  no  notice  of  it;  was  for 
several  nights  afterwards  engaged  in  the  same  diversion,  and 
followed  his  daily  labour.  On  the  ninth  day  from  that  on  which 
he  received  the  blow,  he  thought  that  his  forehead  was  somewhat 
swollen,  and  felt  tender  to  the  touch;  on  the  eleventh  it  was  more 
tumefied  and  more  painful,  and  on  the  twelfth  he  found  himself 
so  much  out  of  order,  that  he  applied  to  be  received  into  St. 
Bartholomew's  hospital. 

An  incision  was  made  into  the  tumor;  a  thin  brown  ichor  was 
discharged;  and  a  bare  bone  being  discovered,  a  circular  piece  of 
the  scalp  was  removed,  which  discovered  a  fracture.  The  tre- 
phine was  applied  twice  along  the  track  of  the  fracture,  by  which 
means  it  was  almost  totally  removed.  The  dura  mater  was  found 
discoloured,  and  beginning  to  have  matter  on  its  surface.  The 
patient  was  let  blood,  and  ordered  to  take  the  sal  absinth,  mix- 
ture, with  a  few  grains  of  rhubarb  in  it  every  six  hours.  The 
succeeding  night  was  passed  ill;  the  patient  complained  much  of 
pain,  and  got  little  or  no  sleep.  On  the  fourteenth  his  fever  was 
high,  his  skin  hot,  and  his  pulse  full  and  hard;  fourteen  ounces 
more  of  blood  were  taken  from  one  of  the  jugulars;  and  as  he 
still  continued  costive,  a  lenitive  purge  was  given  a  few  hours 
afterwards.  On  the  seventeenth  every  thing  bore  a  bad  aspect, 
both  as  to  his  wound  and  his  general  state;  he  got  no  rest,  his 
fever  was  high,  and  the  wound  very  ill  conditioned.  His  head 
was  again  carefully  examined,  in  order  if  possible  to  discover 
some  other  injured  part.     No  such  injury  was  found;  and  it  being 


1S4  INJURIES  OP  THE  HEAD 

impossible  that  he  should  remain  in  his  present  state,  evacuation 
seemed  to  be  his  only  chance,  and  therefore  fourteen  ounces  more 
of  blood  were  drawn  from  one  of  the  temporal  arteries,  by  which 
he  fainted,  and  afterwards  seemed  to  be  somewhat  easier. 

For  three  days  from  this  time  he  seemed  to  be  considerably 
better;  but  on  the  twenty-first  he  was  again  in  as  much  pain  as 
ever,  and  the  sore  again  began  to  put  on  a  bad  aspfect. 

The  benefit  which  he  had  once  already  received  from  phleboto- 
my had  been  manifest;  and  as  his  pulse  was  well  able  to  bear  it 
again,  the  temporal  arteries  were  again  opened,  and  he  was  bled 
till  his  pulse  failed  so  much  and  so  suddenly,  that  I  was  not  a 
little  alarmed.  By  proper  care  he  was  brought  to  himself,  and  I 
had  no  other  trouble  during  his  cure  than  what  proceeded  from 
his  extreme  weakness,  which  the  bark  soon  removed. 

Although  this  man  may  very  justly  be  said  to  have  been  saved 
by  the  frequent  repetition  of  phlebotomy,  yet  as  matter  was 
beginning  to  be  formed  on  the  surface  of  the  dura  mater,  and  as 
such  matter  could  have  no  outlet  whereby  to  escape,  it  is  very 
clear,  that,  unless  the  cranium  had  been  perforated,  he  must  have 
perished. 


CASE  XIX. 

The  driver  of  a  post-chaise  was  thrown  fi'om  his  horse  near 
Ware  in  Hertfordshire,  and  struck  his  head  against  what  they 
call  a  stepping  stone  in  a  wash-way.  He  was  stunned  by  the 
blow,  and  carried  into  a  public,  house;  but  in  half  an  hour's  time 
found  himself  so  well  as  to  be  able  to  carry  the  chaise  to  the  place 
he  was  going  to,  which  was  just  by.  The  next  day  finding  him- 
self perfectly  well,  he  went  to  work  again,  and  continued  to  do 
so  for  six  days.  On  the  seventh,  he  found  himself  sick,  vomited 
twice,  and  had  a  kind  of  fainting  fit  followed  by  a  great  pain  in 
his  head,  and  some  degree  of  fever.  From  the  hardship  and  the 
irregular  manner  of  these  people's  living,  his  complaints  were 
supposed  to  be  owing  to  cold,  and  to  intemperance,  and  he  was 
treated  accordingly:  but  on  the  ninth  day,  a  tumor  appearing  on 
that  part  of  his  head  which  had  received  the  blow,  a  surgeon  ex- 


PROM  EXTERNAL  VIOLENCE.  125 

amined  it,  and,  upon  opening  the  tumefied  part,  found  a  fissure 
running  diagonally  across  the  whole  parietal  bone.  The  next 
day  he  was  brought  to  St.  Bartholomew's  hospital.  His  skin 
was  hot,  his  pulse  hard  and  quick,  and  he  complained  that  his 
head  felt  as  if  it  was  squeezed  between  two  trenchers.  The 
whole  fissure  being  brought  into  view,  the  trephine  was  applied 
three  times  along  the  track  of  it;  from  each  perforation  a  quan- 
tity of  matter  was  discharged,  and  under  each  the  dura  mater 
was  much  altered.  All  possible  care  was  taken  of  him,  but  to 
no  purpose:  every  day  produced  an  exasperation  of  his  symp- 
toms. On  the  fourteenth  he  became  paralytic  on  one  side,  and 
on  the  sixteenth  sunk  into  a  state  of  perfect  insensibility,  and 
toward  evening  died.  The  whole  internal  surface  of  the  left 
parietal  and  temporal  bones  was  detached  from  the  dura  mater, 
and  covered  a  large  quantity  of  matter. 


CASE  XX. 

A  bricklayer's  labourer  was  knocked  down  by  the  fall  of  a 
large  heavy  pantile,  which  made  a  large  wound  in  the  scalp,  and 
broke  the  scull.  The  fracture  began  in  the  left  parietal  bone, 
and,  traversing  the  coronal  suture,  ran  about  an  inch  in  the  os 
frontale. 

He  was  soon  brought  to  the  hospital,  where  the  scalp  was  im- 
mediately removed,  so  as  to  make  way  for  the  trephine;  which 
instrument  was  applied  on  each  side  of  the  suture,  in  such  man- 
ner as  to  comprehend  the  fracture  in  each  application  of  it. 

The  dura  mater  was  found  to  be  uninjured;  there  was  neither 
extravasation,  nor  any  other  mark  of  mischief.  The  patient  was 
freely  and  repeatedly  let  blood,  kept  to  a  proper  regimen,  and  pre- 
scribed for  by  the  physician.  In  two  months  he  was  discharged 
perfectly  well,  and  had  not  during  his  cure  one  single  bad  symp- 
tom. 

It  may  very  reasonably  be  remarked,  that  this  was  one  of  those 
cases  which  might  have  done  well  without  the  operation,  which  I 
am  much  inclined  to  believe:  but  does  not  this  case,  as  well  as 


126  INJURIES  OF    THE    HEAD^ 

many  others  of  like  sort,  prove  also,  that  the  laying  bare  the  un- 
injured dura  mater  is  not  a  matter  of  such  hazard,  as  some  have 
supposed  it  to  be? 


CASE  XXI. 

A  GIRL  about  nine  years  old  fell  from  the  top  of  a  pretty  high 
hay  rick  at  Islington,  and  pitched  with  her  head  on  the  ground, 
which  was  hard  and  dry.  She  was  carried  home  bleeding  freely 
from  a  wound  on  one  side  of  the  upper  part  of  the  head,  and  a 
surgeon  in  the  neighbourhood  examining  her,  found  that  her  scull 
was  broken;  upon  which  she  was  brought  to  the  hospital.  The 
fracture  was  detected;  it  began  in  one  parietal  bone,  and,  passing 
the  suture,  ended  in  the  other,  making  a  course  of  about  three 
inches  in  all.     It  was  open,  and  blood  discharged  through  it. 

The  trephine  was  applied  to  it  on  each  bone;  the  dura  mater 
was  not  hurt.  She  had  neither  sickness,  stupor,  pain,  nor  fever, 
and  got  well  without  any  trouble;  not  even  an  exfoliation  from  the 
bare  cranium. 

The  same  remarks  as  were  applicable  to  the  foregoing  case 
are,  perhaps,  equally  so  to  this. 


CASE  XXII. 

A  farrier's  servant  received  a  blow  from  the  foot  of  a  horse 
which  he  was  shoeing.  The  blow  knocked  him  down,  and  be- 
reaved him  of  sense.  He  lived  near  Smithfield,  and  was  brought 
to  the  hospital  senseless. 

I  saw  him  in  less  than  half  an  hour,  and  found  him  to  all  ap- 
pearance well,  his  senses  perfectly  recovered,  and  no  remains  of 
the  injury  visible,  save  a  small  bruise  on  his  forehead.  A  discu- 
tient  cerate  was  applied  to  the  bruise,  he  was  let  blood,  a  purge 
was  ordered  for  the  next  day,  and  he  was  advised  to  keep  very 
quiet. 

On  the  third  day  he  was  perfectly  well,  had  no  general  com- 


FROM  EXTERNAL  VIOLENCE.  127 

plaint,  and  the  bruise  on  his  forehead  was  what  is  commonly  called 
black  and  blue- 
He  continued  well  until  the  evening  of  the  seventh  day,  in 
which  he  complained  of  being  faint,  chilly,    and  uneasy  in  his 
head,  particularly  his  forehead.    The  following  night  he  was  rest- 
less, and  in  the  morning  was  sick  and  giddy,  and  had  no  appetite. 
His  pulse  was  very  little  risen;  however,  twelve  ounces  of  blood 
were  taken  from  his  arm,  and  he  was  ordered  to  take  the  sal  ab- 
sinth, mixture  sextis  horis,  and  keep  in  bed.     The  ninth  and  tenth 
days  were  passed  in  much  the  same  manner;  but  on  the  eleventh 
his  fever  rose  high,  and  the  part  of  his  forehead  which  had  re- 
ceived the  blow  became  swollen  and  tender.     On  the  thirteenth 
the  tumefied  part  palpably  contained  a  fluid,  and  was  therefore 
opened.     A  fracture  about  two  inches  in  length  was  discovered, 
running  from  just  above  the  frontal  sinus  upward.     The  trephine 
wa?  applied  in  the  most  depending  part,  and  matter  found  between 
the  membrane  and  bone.     The  day  after  this  operation,  finding 
his  pulse  to  be  full  and  hard,  I  bled  him  so  freely  that  he  swooned, 
and  was  some  minutes  before  he  recovered.    That  night  he  passed 
much  easier;  and  although  the  discharge  of  matter  was  consider- 
able for  some  time,  yet,  by  proper  care  and  due  management,  both 
physical  and  chirurgical,  he  got  well. 

I  will  not  assert  it  to  be  a  general  fact,  but  as  far  as  my  own 
experience  and  observation  go,  I  think  that  I  have  seen  more  pa- 
tients get  well,  whose  injuries  have  been  in  or  under  the  frontal 
bone,  than  any  other  bones  of  the  cranium.  If  this  should  be 
found  to  be  generally  true,  may  not  the  reason  be  worth  inquiring 
into.'* 

*  That  this  is  true,  has  been  proved  by  many  instances.  The  cause  is  in 
great  measure  assigned,  if  we  recollect  that  the  cerebrum  may  be  hurt  with 
less  danger  than  the  cerebellum  ;  and  that  the  greater  the  distance  of  a  wound 
from  the  cerebellum,  the  less  danger  there  is  of  that  part  of  tlie  contents  of 
the  cranium  being  injured.  It  has  been  frequently  demonstrated,  that  great 
part  of  the  cerebrum  may  be  taken  away  without  destroying  the  animal,  or 
even  depriving  it  of  its  faculties ;  whereas  the  cerebellum  will  scarcely  admit, 
the  smallest  injury,  without  being  followed  by  mortal  symptom?.  K. 


INJURIES  OF  THE  HfeAD 


CASE  XXIII. 


A  LAD  about  seveoteen,  the  son  of  a  plasterer,  was  at  work  with 
his  father  at  the  mansion-house,  and  fell  from  a  scaffold  a  consi- 
derable height.  He  lay  senseless  for  some  minutes,  but  in  a  little 
time  was  so  much  recovered  as  to  walk.  On  the  left  side  of  his 
head  was  a  small  bruise,  which  gave  him  little  or  no  pain.  He 
had  no  symptoms  which  indicated  that  he  had  sustained  any  mis- 
chief; and  after  having  staid  at  home  a  day  or  two  at  the  per- 
suasion of  his  mother,  he  returned  to  his  business.  On  the  ninth 
day  from  that  of  his  fall,  he  was  seized  with  a  violent  shooting  paio 
in  his  head,  was  sick,  and  had  a  kind  of  convulsive  fit. 

As  it  was  not  supposed  that  his  fall  had  any  share  in  that  attack, 
no  notice  was  taken  of  it;  a  few  ounces  of  blood  were  drawn  from 
his  arm,  and  the  apothecary  who  had  the  care  of  him  gave  him 
some  of  those  medicines  that  are  called  nervous. 

His  head-ach,  fever,  and  watching,  continued  without  remis- 
sion for  several  days,  and  at  the  end  of  three  weeks  he  died,  para- 
lytic on  one  side,  and  convulsed  on  the  other. 

A  small  swelling  having  appeared  on  his  head  three  or  four  days 
before  his  death,  his  father  desired  me  to  come  and  look  at  it,  aftei* 
that  event  had  happened. 

The  pericranium  was  separated  from  the  left  parietal  bone  quite 
across,  by  means  of  a  fracture  which  traversed  the  length  of  the 
whole  bone.  A  quantity  of  matter  was  lodged  between  the  inner 
surface  of  the  said  bone  and  the  outer  one  of  the  dura  mater,  and 
a  smaller  collection  of  matter  was  also  found  between  the  mem- 
brane and  the  pia  mater. 


CASE  XXIV. 

A  YOUNG  man  about  twenty-two  was  brought  into  St.  Bar- 
tholomew's hospital,  considerably  hurt  by  a  fall  from  a  high 
scaffold. 

The  radius  of  his  right  arm  was  broken  about  its  middle;  the 


T^ROM  EXTERNAL  VIOLENCE.  121) 

tibia  and  fibula  of  his  left  leg  were  both  broken,  and  one  or  two  of 
his  ribs. 

By  proper  care,  in  about  five  weeks,  he  was  so  well  as  to  be 
permitted  to  get  out  of  bed.  The  first  day  of  his  rising  he  com- 
plained of  being  sick  and  giddy,  which  was  imputed  to  weakness 
and  confinement,  and  therefore  disregarded.  For  three  or  four 
days  after  this  period  he  complained  of  constant  pain  in  his  head, 
got  no  sleep,  and  was  constantly  feverish.  As  he  had  never  made 
any  complaint  of  his  head,  nor  had  apparently  sustained  any  in- 
jury on  that  part,  Mr.  Nourse  (whose  patient  he  was)  could  not 
suspect  any,  and  therefore  contented  himself  with  the  common 
antiphlogistic  regimen.  At  the  end  of  the  sixth  week,  he  com- 
plained that  his  head  was  painful  to  the  touch;  and,  the  day  after 
he  had  made  this  complaint,  he  had  a  severe  rigor,  which  lasted 
half  an  hour.  On  the  twenty-ninth  day,  a  swelling,  palpably 
containing  a  fluid,  appeared  on  one  side  of  his  head.  Mr.  Nourse 
opened  it,  and  found  a  fracture  of  the  parietal  bone  three  inches 
long  at  least,  through  which  matter  issued  freely.  The  trephine 
was  applied,  a  large  quantity  of  matter  was  discharged,  and  the 
dura  mater  was  found  sloughy;  under  which  sloughy  part  was 
another  collection  of  matter  between  the  membranes,  and  under 
this  latter  abscess  the  brain  was  considerably  discoloured.  He 
died  on  the  fiftieth  day  from  that  of  his  fall. 


CASE  XXV. 

A  Bot,  belonging  to  a  horse-dealer  in  Smithfield,  was  thrown 
from  a  horse,  with  great  violence,  against  one  of  the  sheep-pens. 
He  had  a  large  wound  and  a  fracture,  which  began  about  the 
middle  of  the  frontal  bone,  and,  passing  the  coronal  suture,  ended 
in  the  right  parietal. 

A  trephine  was  set  on  the  fracture  in  the  frontal  bone,  and  a 
small  quantity  of  grumous  blood  discharged  from  between  the 
cranium  and  dura  mater.  All  that  day  and  night  he  continued 
senseless;  but  the  next  day,  by  means  of  a  second  plentiful  bleed- 
ing, he  recovered  his  senses.     To  render  every  thing  (as  I  hoped) 

VOL.  r.  Br 


1^0  INJURIES  OB^  THE  HEAD 

secure,  a  small  trephine  was  applied  on  the  other  side  of  the  su- 
ture, which  seemed  to  comprehend  all  the  breach  made  in  the  pa- 
rietal bone. 

For  nine  days  from  this  time  every  thing  looked  well,  and  the 
boy  was  free  from  complaint;  but,  on  the  twelfth  from  the  acci- 
dent, he  complained  of  being  much  out  of  order;  and  the  next  day 
the  sore  looked  ill,  and  a  thin  gleet  was  discharged  from  the  dura 
mater  through  the  lint,  which  now  stuck  fast  to  it,  instead  of 
coming  off  easily  as  usual,  and  covered  with  good  matter. 

For  three  days  from  this  time,  both  the  boy  and  sore  remained 
in  much  the  same  state.  On  the  seventeenth,  in  dressing  him,  I 
observed  a  spongy  kind  of  papilla  on  one  part  of  the  sore,  which 
was  very  tender  to  the  touch,  and  from  which  was  discharged, 
upon  pressure,  a  thin  sanious  kind  of  fluid:  by  means  of  a  probe 
passed  through  this  papilla,  I  discovered  a  sinus  with  bare  bone 
its  whole  length:  the  division  of  this  detected  a  capillary  fissure,  of 
at  least  two  inches  in  length.  A  trephine  was  set  on  it,  and  the 
dura  mater  was  found  discoloured,  and  with  matter  on  its  surface. 
By  means  of  free  evacuation  at  first,  and  as  free  use  of  the  bark 
afterwards,  this  patient  got  well. 


CASE  XXVI. 

Two  female  inhabitants  of  St.  Giles's  got  drunk  together,  and 
quarrelled;  one  of  them  threw  a  stool  at  the  other,  and  knocked 
her  down.  The  edge  of  the  stool  cut  through  the  scalp,  and 
broke  the  left  parietal  bone.  The  fracture  ran  from  the  middle 
of  the  bone  as  far  as  the  sagittal  suture.  The  girl  was  dressed 
that  night  by  somebody  in  her  neighbourhood,  and  was  brought 
the  next  morning  to  the  hospital.  As  she  had  no  bad  symptom  of 
any  kind,  the  operation  was  deferred,  and  she  went  on  very  well 
for  a  week;  at  the  end  of  which  time  she  began  to  complain  in 
such  manner,  and  her  sore  shewed  such  an  aspect,  that  I  thought 
Uiere  must  be  mischief  under  the  cranium.  A  trephine  was  set 
on  the  fracture;  the  dura  mater  was  found  sloughy  and  purulent. 
She  was  bled  again  freely,  and  took  proper  medicines.  On  the 
fifteenth  day  she  had  tV  shivering,  and  after  it  a  very  brifikXever. 


PROM  EXTERNAL  VIOLENCE,  131 

On  the  seventeenth  she  was  worse  in  every  respect.  On  the 
eighteenth  a  tumor  appeared  on  the  other  side  of  the  head.  This 
was  opened,  and  a  fissure  discovered  in  the  right  os  parietale.  A 
trephine  was  set  on  this  fissure,  and  a  discharge  given  to  a  large 
quantity  of  matter.  Every  thing  that  could  be  done  for  her  was 
done;  but  on  the  twenty -third  day  she  died. 

The  dura  mater  was  separated  from  both  the  parietal  bones, 
and  matter  found  in  large  quantity  under  each. 

It  was  for  many  years  a  generally  received  opinion,  that  one 
use  of  the  sutures  of  the  cranium  was,  to  prevent  the  passage  of 
a  fracture  from  one  of  the  bones  to  another. 

This  purpose  they  may  undoubtedly  have  often  accidentally 
served;  but  that  they  are  generally  incapable  of  so  doing,  mani- 
fold experience  evinces.  Fractures  are  often  seen  to  pass  regu- 
larly through  a  suture,  from  one  bone  to  the  adjoining,  without 
any  discontinuation  or  impediment.  This  is  a  fact  which  ought,  by 
writers,  and  lecturers,  to  be  constantly  inculcated,  as  an  inattention 
to  it  may  be  of  very  bad  consequence  to  individuals;  for  the 
practitioner  who  supposes  that  a  suture  will  certainly,  or  not 
unfrequently,  set  bounds  to  a  fracture,  will,  when  he  has  traced 
such  a  kind  of  breach  in  one  bone  as  far  as  the  suture  into  which 
it  may  happen  to  run,  not  think  it  at  all  necessary  to  go  farther 
and  examine  the  adjoining  bone. 

A  suspicion  of  the  stricter  adhesion  of  the  dum  mater  to  the 
scull  at  the  places  of  these  sutures  than  every  where  else,  the 
situation  of  what  are  called  sinuses  immediately  under  the  sutures, 
and  a  fear  that  either  high  and  dangerous  inflammation  must 
follow  the  violent  detachment  of  a  part  of  them,  or  that  an  unre- 
strainable  and  fatal  hasmorrhage  must  ensue  from  a  breach  of  those 
vessels  which  pass  from  the  sinuses  through  the  sutures,  have  deter- 
jed  most  of  our  ancestors  from  meddlhig  with  them,  and  induced 
them  to  deliver  down  to  us  frequent  prohibitions  against  the  appIi-» 
cation  of  perforating  instruments  upon  them.  Neither  of  these 
apprehensions  is  founded  in  fact,  or  in  strict  truth.  The  sepa- 
ration of  the  scull  from  the  longitudinal  sinus  is  not  attended  neces- 
sarily with  any  kind  or  degree  of  inflammation  peculiar  to  itself^ 
or  more  than  any  other  part  of  the  dura  mater;  nor  is  the  lacera' 
Hon  or  breach  of  the  communicating  vessels  between  this  sinus 


130^  INJURIES    OP   THE   HEAD 

and  the  suture  which  covers  it,  necessarily  followed  by  any  such 
degree  of  haemorrhage  as  to  prove  hazardous  or  alarming;  as  I 
have  more  than  once  experienced. 

A  perforating  instrument  most  certainly  ought  not  wantonly  or 
unnecessarily  to  be  set  on  this  part;  and  this  for  a  reason  not 
drawn  from  any  peculiar  hazard  attending  such  operation.  The 
larger  size,  and  greater  number  of  vessels  here  than  in  other  parts 
of  the  bone,  will  certainly  ceuse  such  a  degree  of  bleeding,  or 
haemorrhage,  as,  though  easily  restrainable  when  the  piece  of  bone 
is  removed,  may  yet,  in  the  act  of  perforation,  considerably  em- 
barrass and  perplex  a  young  operator:  it  will  therefore  behove 
him,  in  general,  to  avoid  comprehending  the  sulure  within  his 
saw;  but  still  it  is  right  that  he  should  know,  that,  when  parti- 
cular circumstances  render  it  absolutely  necessary,  such  thing 
may  be  done  very  consistently  with  his  patient's  safety.  Not 
only  a  part  of  the  sagittal  suture,  covering  the  longitudinal  sinus, 
may  be  removed  with  a  trephine,  if  necessary,  and  no  hazard  be 
incurred  from  the  breach  of  the  attaching  vessels;  but  a  wound 
of  the  sinus  itself  is  by  no  means  necessarily  attended  with  an 
unrestrainable  or  fatal  haemorrhage. 

The  very  writers  themselves,  who  are  so  apprehensive  of  a 
wound  of  this  part,  forget  the  relations  they  every  now  and  then 
give  us  of  fragments  of  broken  bone  safely  extracted  from  it. 

A  mistake  concerning  the  nature  of  the  sinuses  was  (I  suppose) 
the  foundation  of  these  apprehensions.  The  idea  which  most  of  our 
ancestors  had  of  the  motion  of  the  dura  mater  induced  them  to 
believe,  that,  as  the  sinuses  were  composed  of  this  membrane,  a 
wound  made  in  them,  like  a  wound  in  an  arterial  tube,  could 
hardly  re-unite.  It  is  now  universally  known  that  they  are  merely 
venal,  and  that  there  is  no  such  impediment  to  the  immediate 
coalescence  of  a  wound  in  them,  when  it  may  happen  to  be  acci- 
dentally inflicted. 

CASE  XXVII. 

A  BOY,  about  eight  years  old,  the  son  of  a  Jew  merchant  in 
the  city,  received  a  blow  on  his  head  with  a  stick  from  his  tutor. 


FROM   EXTERNAL  VIOLENCE.  133 

The  stroke  made  him  giddy  for  a  few  minutes;  but  as  no  blood 
was  shed,  and  the  pain  soon  ceased,  he  concealed  it  till  it  was 
discovered  by  his  barber  that  his  head  was  swollen  in  that  part. 
In  the  middle  of  the  top  of  his  head  was  a  tumor,  about  the  size 
of  a  common  walnut:  it  was  indolent,  had  a  dull  kind  of  pulsa- 
tion, and  palpably  contained  a  fluid. 

Mr.  Serjeant  Amyand  and  Mr.  Shipton  were  joined  with  me. 
In  their  presence  I  divided  the  tumor  with  a  knife,  and  let  out  a 
quantity  of  fluid  venal  blood.  When  as  much  had  been  dis- 
charged as  the  tumor  might  be  supposed  to  have  contained,  we 
were  surprised  to  find  the  blood  still  continue  to  flow,  plainly  not 
from  the  wounded  scalp,  but  from  the  bottom  of  the  cavity. 

Upon  examination,  it  was  found  that  the  sagittal  suture  was 
broken,  that  a  portion  of  the  fracture  was  forced  into  the  sinus,  and 
that  the  blood  issued  by  the  sides  of  this  fragment. 

Extraction  of  this  fragment  was  attempted,  but  to  no  purpose. 
By  the  direction  of  the  consultants,  I  made  a  small  perforation  on 
one  side  of  the  suture;  but  when  that  was  done,  the  point  of  the 
elevator  could  not  be  so  introduced  as  to  get  the  broken  piece  out. 
The  trephine  was  then  applied  on  the  other  side  of  the  suture,  and 
to  the  same  effect,  or  rather  no  effect.  The  fragment  was  only 
capable  of  being  extracted  as  it  had  gone  in.  At  last,  after  much 
deliberation  and  conversation  about  the  hazard  of  wounding  a  sinus, 
(which  was  indeed  already  wounded  by  the  broken  bone,)  it  was 
agreed  to  set  a  trephine  on  the  suture,  in  such  manner  that  the 
whole  surface  should  be  comprehended  within  its  circle.  This 
was  done;  but  when  the  elevator  was  applied,  the  piece  sawed 
came  out  in  fragments,  and  left  the  one  portion  which  had  pierced 
the  sinus  still  sticking  in  it.  We  were  then  necessitated  to  lay 
hold  of  it,  and  extract  it  with  a  pair  of  forceps.  A  flux  of  blood 
followed,  but,  by  the  application  of  a  small  dossil  of  dry  lint,  held 
on  for  a  few  minutes,  it  ceased,  and  never  recurred.  The  patient 
is  alive  at  the  time  of  my  writing  this, 

CASE  XXVIII. 

A  GIRL  about  sixteen  was  knocked  down  by  her  mother  with  an 
iron  poker  of  considerable  weight;  the  latter  immediately  ran 


134  mJURlES  OF  TiiE  HEAD 

away,  and  the  former  was  brought  senseless  to  the  hospital.  She 
had  a  large  wound  on  the  top  of  her  head,  with  a  considerable 
fracture  of  the  sagittal  suture.  The  broken  pieces  were  so  large, 
and  so  loose,  as  to  be  easily  removeable  without  any  perforation. 
When  they  were  taken  away,  the  longitudinal  sinus  was  left  bare, 
at  least  two  inches  in  lengthj  but  no  hjemorrhage  followed  the 
removal  of  the  fragments. 

For  three  days  she  was  bled  twice  a  day,  from  one  part  or  other 
of  her,  and  stools  were  procured  in  such  manner  as  was  possible, 
but  to  no  purpose;  she  still  remained  perfectly  and  absolutely 
senseless.  On  the  fifth  day,  finding  her  still  in  the  same  state, 
and  verily  believing  that  nothing  in  art  could  at  all  serve  her,  I 
made  an  opening  widi  a  lancet  into  the  longitudinal  sinus,  and 
suffered  the  blood  to  run  off,  until  her  countenance,  which  was 
much  flushed,  became  pale,  and  her  pulse,  which  till  now  had 
been  full  and  strong,  though  labouring,  faltered  considerably;  in 
short,  till  she  shewed  as  much  as  a  senseless  person  could  the 
marks  of  a  deliquium  from  inanition.  I  then  put  a  bit  of  lint  on 
the  orifice,  and  ordered  the  nurse  to  keep  her  finger  lightly  on  it 
until  I  had  visited  the  rest  of  the  house.  When  I  returned,  the 
part  shewed  no  disposition  to  bleed  again,  nor  did  it  ever  after. 
That  afternoon  she  opened  her  eyes  and  moved  her  arms,  and  the 
next  morning  was  sensible  enough  to  ask  for  drink.  She  retained 
her  senses  for  several  days,  but  a  fever  coming  on,  she  became 
delirious  and  convulsed,  and  died  so  on  the  seventeenth  day  from 
that  of  her  admission  into  the  hospital. 

Upon  examination,  after  death,  a  considerable  abscess  was 
found  on  the  surface  of  the  brain,  on  one  side  of  the  falciform  pro- 
cess of  the  dura  mater. 


I  should  be  very  sorry  to  be  so  misunderstood,  as  to  have  it  con- 
ceived that  I  have  related  these  cases  with  a  view  to  encourage 
the  opening  of  a  longitudinal  sinus;  that  is  far  from  my  intention. 
I  only  mean,  by  adducing  these  instances,  to  prove  that  our  fears 
of  irremediable  mischief  from  such  wounds,  whether  accidentally 
or  artificially  inflicted,  are  not  well  grounded;  and  that  we  may, 
in  some  desperate  cases,  have  recourse  to  such  means  as  have  been 
supposed  to  be  either  impracticable  or  unwarrantable.     A  surgeon 


PROM   EXTERNAL  VIOLENCE.  135 

should  ever  be  cautious;  but  ill-grounded  apprehensions  will  ne- 
cessarily prevent  improvements,  and  hinder  us  in  some  cases  froin 
attempting  what  may  prove  beneficial  to  mankind.  Had  every 
successor  to  Hippocrates  been  of  his  opinion,  the  operation  of 
lithotomy  had  never  arrived  at  its  present  state  of  i>erfection,  and 
mankind  had  been  suifered  to  languish  under,  and  be  destroyed  by, 
a  most  tedious  as  well  as  excruciating  malady. 


SECT.  V. 

FRACTURES  OF  THE  CRANIUM  WITH  DEPRESSION.. 

.  Simple  fractures  of  the  scull,  or  those  in  which  the  parts  of  the 
broken  bone  are  not  depressed  from  their  situation,  differ  from 
what  are  called  fissures,  only  in  the  distance  of  the  edges  of  breach 
from  each  other.  When  the  separation  is  considerable  it  is  called 
a  fracture,  when  it  is  very  fine  and  small  it  is  called  a  fissure. 
The  chirurgical  intention  and  requisite  treatment  are  the  same  in 
each,  viz.  to  procure  a  discharge  for  any  fluid  which  may  be  ex- 
travasated  in  present,  and  to  guard  against  the  formation  or  con- 
finement of  matter  in  future.  But  in  fractures  attended  with  de- 
pression, the  intentions  are  more.  In  these,  the  depressed  parts  to 
be  elevated,  and  such  as  are  so  separated  as  to  be  incapable  of  re- 
union, or  of  being  brought  to  lie  properly  and  without  pressing  on 
tlie  brain,  are  to  be  totally  removed. 

These  circumstances  are  peculiar  to  a  depressed  fracture;  but- 
although  they  are  peculiar,  they  must  not  be  considered  as  sole, 
but  as  additional  to  all  those  which  have  been  mentioned  at  large 
under  the  head  of  simple  fracture:  commotion,  extravasation,  in- 
flammation, suppuration,  and  every  ill  which  can  attend  on  or  be 
found  in  the  latter,  are  to  be  met  with  in  the  former;  and  will 
require  the  same  method  of  treatment. 

To  free  the  brain  from  pressure,  and  to  provide  a  free  discharge 
ibr  blood  or  lymph  at  present,  or  for  matter  in  future,  by  elevating 


136  INJURIES  OF  THE  HEAD 

the  depressed  pieces,  and  by  removing  such  as  were  loose,  was  as 
well  known  to  the  ancients  to  be  the  proper  curative  intentions, 
as  they  can  be  to  us;  but  the  means  which  tliey  made  use  of  in 
order  to  accomplish  these  ends  were  somewhat  different  to  what 
are  now  used;  and  laboured  under  some  inconveniences  which 
later  practitioners  have  corrected.  This  difference  it  may  be  worth 
while  to  inquire  into. 

Most  of  the  attempts  made  by  our  ancestors,  for  the  elevation 
of  depressed  parts  of  the  cranium,  were  made  by  the  application 
of  instruments  to  the  parts  so  depressed.  This  was  a  palpable 
imperfcQtion,  to  say  no  more  of  it;  but  this  was  not  all;  for  the 
instruments  which  they  made  use  of  on  these  occasions  were  not 
only  to  be  fastened  to  the  depressed  part  of  the  bone,  but  required 
also  some  degree  of  force  to  be  used  in  fastening  them  to  such 
part.  The  troclea  tripes,  the  troclea  bipes,  and  all  the  pieces  of 
machinery  designed  by  Albucasis,  Guido,  Andreas  a  Cruce, 
Fabritius  ab  Aquapendente,  Pare,  and  Scultetus,  as  well  as  thoge 
delineated  by  Hildanus  and  Peter  Paaw,  are  proofs  of  this:  they 
all  require  a  perforation  to  be  made  in  the  depressed  piece,  either 
by  or  for  the  screw'  with  which  it  is  to  be  elevated.  Now,  not  to 
mention  that  most  of  these  instruments  were  so  complex  as  to  ren- 
der them  extremely  awkward  and  unmanageable,  it  is  obvious, 
that,  by  the  application  of  any  of  them  to  the  depressed  pieces, 
(especially  if  they  were  loose,)  all  the  ills  arising  from  pressure 
made  on  the  parts  underneath  must  be  increased;  and  that  in 
many  cases  they  could  not  be  used  at  all.  Celsus  has  indeed 
directed  the  meningophylax  to  be  used  as  an  elevator;  which 
instrument  differs  but  little  from  the  elevator  used  at  present, 
either  in  form  or  manner  of  application;  but  then  the  opening 
through  which  it  is  to  be  introduced  is  to  be  made  either  with  the 
terebra  or  the  cyciiscos,  the  inconveniences  of  which  have  already 
been  remarked.  In  short,  all  the  objections  which  the  old  per- 
forating instruments  were  liable  to  in  simple  undepressed  fractures 
being  of  still  greater  force  in  fractures  with  depression,  and  the 
application  of  any  kind  of  instrument  whatever  to  the  outer  sur- 
face of  a  depressed  or  loose  piece  of  scull  being  palpably  wrong, 
and  liable  to  hazard,  the  present  practitioners  are  certainly  vin- 
d.icable  in  having  laid  them  all  aside,  and  in  having  endeavoured 


TROM  EXTERNAL  VIOLENCE.  137 

to  accomplish  the  same  end  by  means  which  are  less  hazardous 
and  less  operose.  The  trephine  is  (as  I  have  before  observed) 
the  only  perforating  instrument  used  by  the  best  of  the  present 
practitioners  in  England:**  with  this,  an  opening  is  made  in  the 
sound  undepressed  part  of  the  cranium,  and  through  such  opening 
an  instrument,  called  from  its  use  an  elevator,  is  introduced.  This 
perforation  should  either  comprehend  the  border  of  the  fracture, 
where  that  is  possible,  or  if  that  cannot  be  conveniently  done,  should 
be  made  as  near  to  it  as  possible,  for  reasons  too  obvious  to  need  re- 
cital. What  number  of  perforations  may  be  necessary  can  only 
be  determined  by  the  particular  circumstances  of  each  individual 
case:  all  the  intentions  which  may  arise  from  extravasation  of 
fluid,  or  probability  of  suppuration,  as  well  as  those  from  the  de- 
pression of  bone,  nlust  be  fulfilled,  or  the  work  will  be  left  imper- 
fect, and  little  chance  of  good  will  attend  it. 

When  the  whole  disease  seems  to  consist  in  the  mere  depres- 
sion of  the  bone,  and  what  symptoms  attend  seem  to  proceed  from 
that  alone,  the  elevation  of  such  portion  may  procure  immediate 
remission  of  such  symptoms,  and  afford  a  reasonable  prospect  of 
success.  But  as  the  injury  is  not  always  of  so  simple  a  nature,  as 
other  parts  are  so  frequently  hurt  and  other  mischief  done  by  such 
great  violence,  the  remission,  or  disappearance  of  such  symptoms 
as  arise  merely  from  such  pressure,  cannot  be  a  sufficient  war- 
rant, either  for  promising  or  for  expecting  success.  The  dura 
mater  under  the  depressed  piece,  or  even  in  another  part  of  the 
head,  may  have  been  so  hurt  as  to  become  inflamed,  and  to  sup- 
purate: the  symptoms  of  which  will  not  appear  immediately,  nor 
in  general  until  some  time  is  past:  but  however  late  they  may 
come  on,  they  will  not  therefore  be  the  less  certain  or  the 
less  hazardous.  The  early  attack  of  those  which  are  caused 
by  extravasated  fluid    or    depressed   bone,  does  by  no  means 

»  M.  Savigny,  in  his  work  on  Chirurgical  Instruments,  has  exhibited  a  tre- 
phine on  a  new  and  improved  construction,  which  is  divested  of  lateral  teeth, 
and  made  on  the  same  principles  as  the  amputating  saw ;  it  certainly  per- 
forms its  office  with  celerity  and  neatness,  and  with  less  exertion  to  the 
operator  than  that  before  in  use.  The  perforator  having  sufficiently  fixed 
the  saw  in  the  circle,  is  by  a  contrivance  made  to  retire,  which  precludes  the 
necessity  of  removing  it  by  means  of  a  key.        E. 

VOL.  I.  S 


138  INJURIES  OP  THE  HEAD 

preclude  the  later  accession  of  such  as  arise  from  inflamma- 
tion and  putrefaction.  The  depressed  piece  of  bone  does  most 
certainly  require  our  immediate  help,  but  the  assistance  lent  to 
that,  however  proper  and  effectual,  does  not  render  it  at  all  less 
necessary  to  guard  against  such  ill  as  may  most  reasonably  be  ex* 
pected  to  proceed  from  violence  sustained  by  the  parts  underneath. 
A  blow,  which  has  been  sufficient  to  break  and  depress  a  portion 
of  the  scull,  very  frequently  does  such  damage  to  the  tender  ves- 
sels which  communicate  between  that  bone  and  the  meninges,  as 
to  be  the  cause  of  niuch  more,  as  well  as  greater  ill,  than  what  is 
deducible  from  the  mere  fracture;  and  consequently,  although  the 
elevation  of  the  bone  is  one  very  necessary  part  of  a  sui'geon's  bu- 
siness in  these  cases,  yet  it  is  very  far  from  being  all  that  he  has 
to  do.  All  the  ills  which  may  be  apprehended  from  every  other 
possible  effect  of  such  violences,  are  to  be  feared  and  guarded 
against,  and  that  full  as  much  in  the  fracture  with  depression 
as  in  that  without. 

This  is  a  part  of  practice  which  ought  to  be  very  carefully  at- 
tended  to.  The  generality  of  writers  have  contented  themselves 
with  directing  us  to  raise  up  the  depressed  parts,  and  thereby  to 
endeavour  to  remove  such  symptoms  as  are  caused  by  the  mere 
pressure  which  the  bone  makes  on  the  brain;  but  have  either  to- 
tally neglected,  or  very  slightly  passed  over,  what  is  of  full  as 
much  consequence  to  the  patient;  I  mean  the  injury  which  is  most 
frequently  done  to  the  membranes  of  the  brain,  and  which,  if  ne- 
glected, will  certainly  produce  that  fever,  and  those  symptoms, 
which  so  often  baffle  the  whole  power  of  medicine. 

The  combination  of  different  ill  effects,  proceeding  from  the 
same  primary  violence,  and  concurring  in  the  same  subject,  to- 
gether with  the  great  difficulty  of  distinguishing  them  from  each 
other,  is  one  of  the  principal  causes  of  that  perplexing  uncertainty 
attending  wounds  of  the  head.  When  one  cause  of  bad  symp- 
toms has  been  removed,  another,  or  even  several  others,  may  still 
remain,  each  of  which  singly  may  be  sufficient  to  destroy  the  pa- 
tient; and  therefore,  although  the  means  first  made  use  of  may 
have  been  such  as  have  been  pointed  out  by  the  earliest  and  most 
alarming  symptoms,  and  extremely  proper  for  the  relief  of  such 
complaint,  had  it  been  the  only  one  the  patient  laboured  under, 


FROM  EXTERNAL  VIOLENCE,  139 

yet  in  the  case  of  a  complication,  by  not  being  sufficient  to  an- 
swer every  requisite  intention,  they  very  often  answer  none,  at 
least  not  effectually;  and  producing  only  a  temporary  and  partial 
relief,  prove  a  greater  aggravation  of  our  disappointment. 

This  every  practitioner  should  know,  and  this  the  friends  of 
every  patient  should  be  made  acquainted  with,  lest  the  former,  be- 
ing deceived  by  an  appearance  of  amendment,  be  induced  to  pro- 
mise what  it  will  not  be  in  his  power  to  perform;  and  the  latter, 
having  had  their  hopes  exalted,  should  be  the  more  severely  hurt 
by  their  disappointment. 

If  the  fracture  be  but  small,  the  depression  little,  and  the  force 
with  which  it  was  produced  not  great,  the  elevator  introduced 
through  the  perforation  may  be  sufficient  to  set  it  to  rights;  and  if 
there  be  no  urgent  symptoms,  nor  any  mischief  done  to  the  inter- 
nal parts,  may  be  sufficient  for  all  purposes.  But  if  the  force  was 
great,  if  the  symptoms  are  immediate  and  pressing,  if  the  fracture 
runs  in  a  form  inclined  to  a  circular  one,  or  if  the  depressed  piece 
be  cracked  all  round,  the  best  and  safest  way  is  to  remove  the 
whole,  or  greater  part,  of  the  portion  so  depressed  or  circam- 
scribed. 

To  those  who  are  unused  to  things'  of  this  sort,  so  large  an 
opening  as  such  method  of  acting  must  make  will  have  a  very 
tremendous  appearance;  and  they  may  be  inclined  to  suspect 
much  hazard  and  inconvenience  from  laying  bare  so  large  a  por- 
tion of  the  dura  mater;  but  let  all  such  remember,  that  however 
large  the  quantity  of  membrane  may  be  which  shall  be  thus  de- 
nuded by  the  operation,  yet  the  same  quantity  at  least,  most  pro- 
bably a  much  larger,  would,  in  all  likelihood,  become  inflamed,  and 
generate  matter  on  its  surface;  which  matter,  for  want  of  a  timely, 
ready,  and  sufficient  outlet,  would  do  considerably  more  mischief 
than  the  mere  detection  of  the  said  membrane  can  do. 

In  cases  where  the  broken  pieces  of  a  depressed  fracture  are 
widely  separated  from  each  other,  and  some  of  them  a  good  deal 
loosened,  the  expediency  and  the  propriety  of  removing  such  pieces 
are  acknowledged  by  every  body;  but  few  people  attend  to  the 
reason,  or  inquire  why  such  practice  is  just  and  proper;  if  they  did, 
thev  would  also  see  that  the  free  removal  af  bone  was  equally 


140  INJURIES  OP  THE  HEAD 

proper  in  the  case  of  great  violence,  as  in  that  of  loosened  or 
widely  separated  pieces.  In  the  latter  the  broken  parts  are  re- 
moved, because  their  reunion  with  the  rest  of  the  cranium,  and 
the  preservation  of  the  attachment  of  the  dura  mater  to  the  inner 
surface  of  them,  is  thought  impossible,  or  at  least  highly  impro- 
bable; and  that  therefore  they  must  be  in  the  way,  arid  hinder  the 
free  discharge  of  matter  from  the  suppurating  membrane.  And 
is  not  the  same  inconvenience  full  as  likely  to  attend  the  former? 
Is  it  the  violence  done  to  the  bone,  and  through  it  to  the  mem- 
brane, which  causes  the  inflammation  and  suppuration?  Oris  it 
the  loosened  or  separated  state  of  the  broken  part?  If  it  be  the 
former,  (as  it  most  undoubtedly  must  be,)  the  same  precautions,  the 
same  method  of  treatment  must  be  equally  necessary  in  the  one  as 
in  the  other;  the  reasons,  the  intentions,  are  the  same  in  each: 
and  if  the  conduct  be  not  the, same  the  patient  will  suffer. 

The  peculiar  circumstances  of  each  individual  case  must  fur- 
nish direction  to  the  practitioner  for  his  particular  conduct.  Rules 
to  be  laid  down  by  a  'writer  on  such  subject  can  be  only  general. 
The  parts  which  are  depressed  must  be  elevated;  such  as  are 
loose  and  cannot  be  brought  to  lie  even,  such  as  cannot  be  pre- 
vented from  pressing  on  the  membrane,  or  such  as  wound  and  ir- 
ritate it,  must  at  all  events  be  taken  away;  the  free  discharge  of 
blood  or  lymph  in  present,  and  of  matter  in  future,  must  be  pro- 
vided for;  and  therefore  every  symptom  and  appearance  must 
carefully  and  early  be  attended  to,  lest  the  most  proper  opportu- 
nity of  giving  assistance  be  not  embraced. 

The  circumstances  just  mentioned  are  such  as  cannot  be  ne- 
glected but  at  the  risk  of  the  patient;  and  therefore  the  prohibi- 
tions which  our  forefathers  have  delivered  down  to  us,  with  regard 
to  the  parts  of  the  scull  on  which  they  say  we  ought  not  at  any 
rate  to  apply  our  perforating  instruments,  must  be  received  with 
some  limitation. 

The  places  forbidden  as  improper  are,  the  sutures,  the  lower 
part  of  the  os  occipitale,  the  ossa  temporum,  and  that  part  of  the 
OS  frontale  where  the  sinuses  are  situated. 

That  a  trephine  may  without  hazard  be  applied  on  a  suture,  I 
have  already  said.  ,  When  it  may  with  equal  utility  be  set  on  any 
other  part,  the  sutures  should  undoubtedly  be  avoided,  and  that 


FROM  EXTERNAL  VIOLENCE.  141 

for  a  good  reason,  exclusive  of  any  peculiar  hazard:  but  that  part 
of  a  suture  may  (the  case  requiring  it)  be  safely  removed,  is  true 
beyond  all  doubt.  That  many  of  the  old  practitioners  were  very 
apprehensive  of  mischief  from  hence,  is  not  to  be  wondered  at  by 
any  body  who  considers  their  idea  of  the  nature  of  the  subjacent 
sinuses,  and  the  strange  unmanageable  instruments  with  which 
they  operated.  Not  that  there  are  wanting  old  writers  who  have 
held  the  doctrine  of  operating  on  a  suture,  when  necessary,  very 
defensible;  among  whom  is  J.  Baptist.  Cortesius. 

Perforation  of  the  temporal  bones  has  been  forbid,  both  on  ac- 
count of  the  artery  and  the  muscle  which  are  on  its  surface;  unre- 
strainable  hasraorrhage  having  been  dreaded  from  the  one,  and 
fatal  convulsion  from  the  other:  but,  experience  may  convince  us, 
that  neither  of  these  apprehensions  is  strictly  just.  The  tempo- 
ral artery,  when  divided,  is  often  capable  of  being  restrained  by 
compression,  and  always  by  ligature;  and  that  fatal  convulsion, 
which  is  vulgarly  called  the  lock-jaw,  though  it  produces  one  of 
its  most  striking  and  most  visible  effects  on  these  muscles,  is  not 
necessarily  produced  by  a  wound  of  either  of  them,  more  than  by 
a  wound  of  any  other.  In  short,  the  upper  part  of  the  temporal 
bones  may  be  laid  bare,  if  necessary,  by  an  incision  made  through 
the  muscles  covering  them;  and  may  also  be  perforated.  Such 
operation  does  not  indeed  often  prove  successful;  but  the  failure 
of  success  does  not  proceed  from  the  nature  of  the  parts  operated 
upon,  but  from  a  circumstance  of  much  more  consequence,  and 
generally  w^ithout  remedy;  which  is,  that  in  these  fractures  the 
breach  is  most  commonly  continued  on  to  the  basis  of  the  scull, 
and  is  also  most  frequently  attended  by  a  large  extravasation 
within  or  under  the  brain  and  cerebellum.^ 

When  the  depressed  parts  have  been  raised  up,  the  loose  ones 
removed,  extravasated  fluid  discharged,  the  brain  freed  from  pres- 
sure, and  way  made  for  the  free  exit  of  whatever  may  be  formed. 
or  collected,  the  bare  dura  mater  should  be  dressed  as  easily  and 

"  Whoever  will  examine  the  clisposilion  of  the  temporal  m\isc]e  will  see, 
that  its  iiponeiirosis  covers  a  verj-  considerable  part  of  the  inferior  border  of 
the  OS  parietale  ;  and,  consequently,  that  such  part  of  tlie  bone  can  never  be 
laid  bai-e  vvilliou'r  a  division  or  removal  of  a  part  of  Ih:-  said  aponevirotic  ex- 
pansion. 


142  INJURIES  OF  THE  HEAD 

lightly  as  possible.  Our  ancestors  had  a  multiplicity  of  medica* 
ments,  which  they  used  upon  these  occasions,  and  wero  very  pre- 
cise in  suiting  them  to  the  different  states  (as  they  called  them) 
of  the  sore  and  membrane.  They  were  also  very  exact  in  making 
and  applying  those  pieces  of  linen  or  of  silk,  called  sindons,  which 
they  used  to  imbue  with  the  said  remedies,  and  dress  the  bare 
dura  mater  with.  I  have  taken  no  notice  of  either,  because  I 
verily  believe  that  the  majority  of  the  former  were  absolutely  use- 
less, and  that  the  very  exact  application  of  the  latter  was  preju- 
dicial, by  confining,  in  some  degree,  what  ought  to  be  discharged 
with  the  utmost  freedom. 

Wounds  of  the  brain,  among  writers  on  this  subject,  have  also 
generally  made  a  distinct  chapter;  but  the  treatment  of  them  is 
so  very  little  different  from  those  which  have  been  already  re- 
lated, that  tjaey  may  fairly  be  comprehended  under  the  same 
article. 

The  brain  is  wounded  either  by  the  instrument,  or  body  whereby 
the  scull  is  broken,  or  by  broken  parts  of  the  cranium;  foreign 
bodies  also,  such  as  bullets,  splinters,  parts  of  weapons,  wadding 
of  fire-arms,  &c.,  are  sometimes  lodged  in  it;  but  let  the  wound  or 
fracture  be  what  it  may,  or  whatever  other  circumstances  may 
happen  to  attend,  the  chirurgic  treatment  is  short  and  plain;  viz. 
to  remove  all  such  parts  of  the  broken  scull,  as  may  press,  wound, 
or  irritate  the  brain  or  its  membranes;  to  take  away  all  such 
extraneous  bodies,  as  can  easily,  and  without  violence,  be  got  at 
and  extracted;  and  to  make  such  an  openyig  as  may  most  conve-^ 
niently  serve  the  purpose  of  discharging  blood,  serum,  or  matter, 
either  in  present  or  in  future.  When  all  these  things  have  been 
done,  and  the  patient  has  been  put  under  a  proper  regimen,  both 
of  diet  and  medicine,  the  surgeon  has  done  his  duty,  and  may  say 
with  Mr.  Pope — 

"  Thv'.s  i'nv  was  rij^lit ;  llie  rest  we  leave  to  heaven." 

For  with  regard  to  the  dressings  proper  in  these  cases,  they  are 
not  at  all  diflVn-ent  from  those  which  ought  to  be  useJ,  where 
neither  the  brain  nor  its  meninges  are  hurt.  They  should  be  soft, 
light,  and  nol:  consist  of  any  tiling  greas> ,  or  which  can  possibly 


PROM  EXTERNAL  VIOLENCE.  143 

irritate  or  inflame;  nor  should  they  be  applied  in  such  manner  or 
quantity  as  to  press  or  obstruct  the  free  discharge  of  fluids  of  any 
kind.  Soft  dry  lint  is  perhaps  equal  to  any  or  all  others.  In  the 
chirurgical  writers  are  to  be  found  a  great  many  formulae:  but, 
whoever  places  confidence  in  them,  for  any  supposed  merit  of  their 
own,  will  find  himself  much  disappointed. 

I  cannot  quit  this  subject,  without  making  a  short  remark  on 
the  bandages  most  frequently  advised,  and  used  in  wounds  of  the 
head. 

In  all  the  writers  on  the  subject  of  fasciae  are  to  be  found  de- 
scriptions and  delineations  of  those  which  are  said  to  be  most 
proper  for  the  head.  On  paper  they  are  neat  and  elegant,  in  the 
application  they  require  a  small  degree  of  practice  and  dexterity, 
and,  when  applied  nicely,  may  impose  on  the  ignorant,  and  on 
those  who  have  not  seen  much  of,  or  reflected  much  on,  their  in- 
convenience. They  press,  heat,  and  painfully  confine  the  head, 
even  when  applied  in  the  best  and  most  ingenious  manner;  and. 
when  put  on  awkwardly  or  negligently,  are  still  more  troublesome, 
and  less  serviceable.  All  that  can  ever  possibly  be  wanted  in 
these  cases  from  bandage  must  be,  merely  to  keep  the  dressings  in 
their  place  without  any  degree  of  confinement  or  pressure;  and 
this  purpose  will  always  be  better  accomplished  by  a  loose  cotton 
or  yarn  night-cap,  than  by  the  nicest  and  most  elaborate  bandage 
that  ever  was  invented.^ 

y  "  On  tliis  subject  I  was  very  glad  to  find  so  very  good  a  judge  as  Oriba- 
sius  of  the  same  opinion. 

"  Hxc  autem  omnia  non  fasciis  continentur,  propter  pondus,  sed  velamento, 
*•  ut  cohibeantur,  neque  cerebri  membrana  gravatur ;  ac  velamenti  media 
"  pars,  quae  terebrato  respondet,  forfice  exciditur,  ut  apertum  fiat,  atque  in 
"  illud  spatium  cana  mollis,  in  extremis  constricta,  duplex  inditur,"  &c. 

•*  Plerique  omnes  non  alia  vinctui'a  terebratos  deligant ;  sed  sola  redemi- 
"culi  circumductione  contenti  sint.  Quinetiam  ipsa  quoque  ulcera  extra 
"  terebrationem,  quoad  fieri  potest,  conari  debemus  sine  fasciis  curare ;  non 
•'  modo  quia  gravantur  compressis  iis  quae  sub  vinculis  imposita  ipsis  fuerant^ 
"  verum  etiam  quia  plus  quam  par  est  califaciunt.  Etenim  quod  in  aliis  par- 
"t;Vius  vinctura,  id  in  capite  positio  praestabit,  ideo  deligare  supervacaueum 
^'erit." 

OnriiAsivs  DefraCt.  ex  Ileliodoro. 


144  INJURIES  OP  THE  HEA1» 


CASE  XXIX. 


A  GIRL,  about  fifteen  years  old,  crossing  Smithlield  on  a  market- 
day,  was  tossed  by  an  ox,  and  fell  with  her  head  on  the  flat  stones 
within  the  posts.  As  her  dress  was  mean,  and  nobody  knew  any 
thing  of  her,  she  was  brought  senseless  into  the  hospital.  She  had 
a  large  bruise  on  the  right  side  of  her  head,  through  which  I 
plainly  felt  a  fracture  with  depression.  The  scalp  being  removed 
from  that  part,  the  fracture  was  found  to  be  large,  and  the  depres- 
sion considerable:  it  traversed  the  os  parietale  from  before  back- 
ward, in  its  middle  part  between  the  sagittal  and  temporal  sutures, 
and  the  depression  was  of  the  upper  part  of  the  bone.  I  applied 
a  trephine  on  the  inferior  and  undepressed  part,  and  by  means  of 
an  elevator  raised  the  whole  to  a  perfect  equality.  Her  head  wa& 
dressed  lightly,  and  sixteen  ounces  of  blood  were  taken  from  her. 
She  passed  the  following  night  very  unquietly,  and  the  next  morn- 
ing was  still  senseless.  She  was  again  freely  bled,  and  a  purge 
was  given,  which  soon  operated.  On  the  third  day,  her  pulse 
admitting,  and  her  circumstances  requiring  it,  she  was  bled  again. 
On  the  fourth  day  she  became  sensible,  and  on  the  fifth  was  sur- 
prisingly well.  She  remained  so  until  the  ninth,  on  the  evening 
of  which  she  complained  of  head-ach,  sickness,  and  giddiness. 
She  was  again  let  blood,  and  put  under  the  direction  of  the  phj'- 
sician,  who  ordered  some  medicines  for  her.  From  the  ninth  to 
the  thirteenth  day,  she  remained  much  the  same;  that  is  to  say, 
feverish,  and  complaining  of  heat,  thirst,  head-ach,  and  watching. 
On  the  fourteenth  she  had  a  severe  rigor,  and  the  sore  on  the  scalp 
as  well  as  the  denuded  dura  mater  wore  a  very  bad  aspect.  From 
this  time  she  became  daily  worse  and  worse,  in  every  respect;  and 
on  the  twentieth  day  from  that  of  the  accident,  she  died,  having 
been  terribly  shaken  by  spasms  for  several  hours. 

All  the  internal  surface  of  the  os  parietale  above  the  fracture 
was  detached  from  the  dura  mater,  and  covered  with  matter, 
which  could  not  obtain  free  discharge  at  the  perforation,  the  mem- 
brane being  inflamed  and  thrust  up  tight  against  it. 

I  will  not  pretend  to  assert,  that  repeated  perforation  of  the  up- 
per part  of  the  bone  would  have  preserved  her;  but  I  must  say, 


PROM  EXTERNAL  VIOLENCE.  145 

as  the  case  turned  out,  it  would  have  been  her  best,  if  not  her  only 
chance;  and  that,  if  I  had  known  at  that  time  as  much  of  these 
cases  as  I  think  I  have  since  learned,  I  should  certainly  have  taken 
away  the  greatest  part,  if  not  the  whole  of  what  had  been  de- 
pressed. 


CASE  XXX.     . 

A  gentleman's  servant,  riding  carelessly  and  hastily  through 
London,  was  thrown  from  his  horse,  and  struck  his  forehead 
against  a  sharp  stone.  There  was  a  considerable  wound  on  the 
scalp,  and  a  fracture,  with  depression  of  the  os  frontale.  The 
man  was  perfectly  deprived  of  sense,  the  bone  was  considerably 
depressed,  and  a  large  quantity  of  blood  issued  from  underneath 
the  depressed  part.  A  trephine  was  applied  on  the  undepressed 
part,  and  the  elevation  accomplished;  he  was  let  blood  freely, 
and  dressed  lightly.  On  the  second  and  third  days  he  was  let 
blood  again.  On  the  fourth  he  recovered  his  senses,  and  from 
that  day  to  the  ninth  seemed  to  go  on  well.  On  the  ninth  in  the 
evening  he  complained  of  pain  and  lassitude,  and  was  ill  that  night 
and  all  the  next  day.  On  the  eleventh  he  was  worse,  and  (to  use 
his  own  words)  said,  his  brains  were  bound  round  with  a  fillet, 
like  a  collar  of  brawn.  His  pulse  was  hard,  frequent,  and  jar- 
ring, his  skin  hot,  and  he  got  no  sleep  at  all.  As  the  man  was 
evidently  and  hastily  getting  into  a  hazardous  state,  I  was  de- 
termined to  try  what  a  free  removal  of  bone  would  do;  and  with  a 
large  trephine  took  away  almost  the  whole  of  what  had  been  de- 
pressed. The  dura  mater  was  not  purulent,  but  dull  in  colour, 
and  smeared  over  with  what  Morgagni  says  is  gelatinis  instar. 

He  was  again  and  again  let  blood,  as  his  pulse  would  bear,  and 
the  physician  ordered  proper  medicines,  for  him.  For  four  days 
from  this  time  he  continued  much  the  same,  but  after  that  every 
thing  changed  for  the  better;  he  took  the  cortex  freely,  and  in  about 
three  months  was  discharged  well. 

As  I  would  not  pretend  to  assert,  that  removal  of  more  bone 
would  have  proved  successful  in  the  preceding  case,  so  neither 
will  I  say  that  the  recovery  of  this  man  was  owing  to  it.     I  can 

VOL.  I.  T 


146  INJURIES  OP  THE  HEAD 

only  say,  I  verily  b-^lieve  both,  and  that  I  am  sorry  I  did  not 
make  the  snme  experiment  in  i)oth.  The  cases  were  materially 
similar;  and  the  analogical  is  the  only  method  we  have  of  reason- 
ing on  subjects  like  this,  wherein  we  cannot  have  demonstration. 


CASE  XXXI. 

A  BOY,  about  fourteen  years  old,  following  a  led  horse,  was  de- 
sired by  the  servant,  in  whose  hand  the  horse  was,  to  strike  him; 
the  boy  did  so,  and  received  a  blow  from  one  of  the  horse's  heels, 
which  brought  him  to  the  ground  senseless.  He  had  on  the  upper 
and  middle  part  of  his  forehead  a  large  wound,  which  disclosed  a 
considerable  fracture,  with  depression. 

The  fracture  ran  nearly  in  a  transverse  direction  across  the 
bone,  and  the  depression  was  of  the  upper  part.  A  trephine  was 
applied,  an  elevator  introduced,  and  the  depressed  part  of  the 
bone  with  some  difficulty  made  to  lie  even.  The  head  was 
dressed  lightly,  and  the  boy  was  let  blood  largely.  He  continued 
senseless  all  that  night,  was  let  blood  twice  the  next  day,  and  had 
a  purge  and  a  clyster.  On  the  fourth  day  he  showed  some  signs 
of  sense;  and  in  two  more,  being  again  let  blood  and  kept  very 
low,  was  quite  sensible.  From  this  day  until  the  fourteenth, 
every  circumstance  was  promising,  but  on  that  day  he  again  be- 
came ill;  his  pulse  from  this  time  was  hard  and  quick,  and,  in 
short,  he  had  for  three  or  four  days  all  the  symptoms  of  mischief 
under  the  cranium.  On  the  nineteenth  I  made  a  large  perfora- 
tion in  that  part  of  the  bone  which  had  been  depressed  and  ele- 
vated, and  gave  discharge  to  a  very  large  quantity  of  offensive 
matfer.  On  the  twenty-second  he  became  delirious  and  convuls- 
ed, and  on  the  twenty-third  he  died. 

I  removed  all  the  upper  part  of  the  cranium,  and  found  the 
dura  mater  altered  in  colour,  and  separated  from  the  whole  frontal 
bone,  from  the  fracture  quite  up  to  the  sagittal  suture;  and  under 
the  said  membrane,  matter  to  the  quantity  of  about  half  an  ounce. 


PROM  EXTERNAL  VIOLENCE.  147 


CASE  XXXII. 


The  following  case  was  sent  me  by  a  very  ingenious  practi- 
tioner at  some  distance  from  London,  and  may,  among  others  of 
like  sort,  sefve  to  prove  that  it  is  not  merely  the  formation  of 
matter  between  the  scull  and  dura  mater,  but  also  the  confinement 
of  it  there,  which  are  the  joint  causes  of  the  bad  symptoms,  and 
of  the  hazard. 

A  boy  fell  from  a  cart  loaded  high  with  hay,  and  pitched  per- 
pendicularly on  his  head.  The  blow  stunned  him  for  a  few  mi- 
nutes, but  he  soon  got  up  again,  said  he  was  not  hurt,  and  walked 
home  with  the  cart. 

As  he  made  no  complaint  at  home,  his  master  took  no  farther 
notice  of  his  fall,  and  the  boy  followed  his  daily  labour  in  the 
farm -yard. 

At  the  end  of  a  fortnight  he  came  to  my  friend,  and  desired 
him  to  look  at  the  swelling  on  the  upper  part  of  the  right  side  of 
his  head.  The  tumor  appeared  to  be  full  of  matter,  and  the  sur- 
geon divided  the  scalp,  and  let  out  a  considerable  quantity.  He 
passed  his  finger  in,  in  order  to  examine  whether  the  cranium 
was  bare  or  not,  and  was  not  a  little  astonished  to  find  it  not  only 
bare  but  considerably  broken.  He  removed  the  tumid  portion  of 
the  scalp;  and  having  so  done,  found  the  distinct  pieces  of  bone 
so  loose  as  to  be  taken  away  without  any  resistance,  and  so  large 
as  together  to  make  nearly  a  third  part  of  the  parietal  bone.  The 
dura  mater  under  them  was  clean,  and  well  incarned. 

The  boy  had  no  one  bad  symptom  from  first  to  last,  came  to 
the  surgeon's  house  every  day  to  be  dressed,  and  was  also  in  the 
farm-yard  daily. 


148  INJURIES  OF  THE  HEAD 


SECT.  VI. 

EXTRAVASATION  AND  COMMOTION. 

Great  and  hazardous  as  the  evils  are  which  proceed  from  frac- 
tures of  the  scull,  thej  do  not  exceed  those  which  are  caused  either 
by  the  extravasation  of  fluids  within  its  cavity,  or  by  the  concus- 
sion or  derangement  of  the  substance  of  the  brain;  whether  we 
regard  the  difficulty  under  which  a  practitioner  labours  in  form- 
ing a  judgment  of  the  true  nature  of  the  case,  or  the  uncertainty, 
or  the  frequent  fatality  of  the  event. 

The  shock  which  the  head  sometimes  receives  by  falls  from  on 
high,  or  by  strokes  from  ponderous  bodies,  does  not  infrequently 
cause  a  breach  in  some  of  the  vessels,  either  of  the  brain  or  its 
meninges;  and  thereby  occasions  extravasation  of  the  fluid,  which 
should  circulate  through  them.  This  extravasation  may  be  the 
only  complaint  produced  by  the  accident;  or  it  may  be  joined 
with,  or  added  to,  a  fracture  of  the  scull.  But  this  is  not  all;  for 
it  may  be  produced  not  only  when  the  cranium  is  unhurt  by  the 
blow,  but  even  when  no  violence  of  any  kind  has  been  offered  to, 
or  received  by  the  head. 

Vertigo,  vomiting,  stupidity,  hsemorrhage,  loss  of  sense  and  mo- 
tion, either  partial  or  total,  are  the  symptoms  of  this  kind  of  mis- 
chief; sometimes  one,  or  more,  sometimes  all,  in  the  same  sub- 
ject. These  symptoms,  which  are  all  easily  accountable  for  from 
extravasation  of  fluid,  and  unnatural  pressure  made  on  the  brain 
and  nerves,  are,  as  I  have  already  at  large  remarked,  frequently 
mistaken  as  indications  of  a  disease  which,  considered  abstracted- 
ly, can  never  cause  them;  I  mean  a  simple  undepressed  fracture 
of  the  cranium:  it  maybe  accompanied  by  them,  but  cannot  cause 
them. 

When  a  fluid  is  extravasated  in  any  considerable  quantity 
within  the  cavity  of  the  cranium,  if  any  bad  symptoms  are  pro- 
duced by  it  at  all,  they  are,  and  must  be,  such  as  indicate  pressure 
made  on  the  brain  and  origin  of  the  nerves;  occasioning  thereby 


FROM  EXTERNAL  VIOLENCE.  149 

either  disturbance  or  abolilion  of  the  offices  of  sense  and  motion; 
and  this  in  different  degree,  according  to  the  quantity,  kind,  and 
situation  of  the  pressing  fluid;  and  to  these  is  sometimes  added 
haemorrhage  from  the  nose  or  ears.  Thus  far,  I  think,  we  may 
pronounce  positively;  but,  to  our  very  frequent  mortification,  we 
find  these  are  the  only  circumstances  which  in  such  case  we  can 
depend  upon,  every  thing  else  which  relates  or  belongs  to  them 
being  involved  in  a  most  perplexing  obscurity.  We  not  only  have ' 
no  certain  infallible  rule  whereby  to  distinguish  what  the  pressing 
fluid  is,  or  where  it  is  situated,  but  we  are  in  many  instances  abso- 
lutely incapable  of  knowing  whether  the  symptoms  be  occasioned 
by  any  fluid  at  all;  for  a  fragment  of  bone,  broken  off  from  the 
internal  table  of  the  cranium,  and  making  an  equal  degree  of 
pressure,  will  produce  exactly  the  same  complaints. 

Sometimes,  indeed,  the  case  is  otherwise;  and,  from  concomi- 
tant appearances,  the  true  nature  of  the  disease  may  with  some 
degree  of  certainty  be  known;  but  this  does  not  happen  very 
often. 

Many  of  our  ancestors,  when  no  fracture  was  discoverable  in 
the  cranium  of  a  person  labouring  under  such  symptoms  as  have 
been  mentioned,  in  consequence  of  violence  offered  to  the  head, 
contented  themselves  with  calling  the  case  a  concussion;  and 
although  they  had  no  very  precise  idea  annexed  to  the  term,  yet 
they  seldom  went  farther  for  a  solution;  like  teeth  and  worms  in 
infants,  or  like  nerves  in  women,  it  satisfied  ignorant  inquirers. 
The  cranium  was  not  broken,  the  mischief  was  out  of  sight,  most 
probably  out  of  reach,  and  they  had  not  often  the  curiosity  or  the 
anatomical  judgment  to  examine  after  death  into  the  real  state  of 
the  case. 

That  a  concussion  or  commotion  of  the  substance  of  the  braia 
is  a  circumstance  which  frequently  happens,  is  a  truth  beyond  all 
doubt;  and  that  it  is  often  the  cause  of  death,  is  as  true;  but  that 
many  of  the  cases  which,  the  scull  being  found  not  broken,  have 
passed  for  concussions,  have  been  really  produced  by  very  diffisrent 
causes,  has  often  been  incontestibly  proved  by  the  examination  of 
such  persons' heads  after  death;  where  such  extravasation  of  blood 
or  lymph,  or  both,  have  been  found,  as  would  fairly  and  ration- 
ally account,  both  for  the  symptoms  and  for  the  event. 


150  INJURIES  OP  THE  HEAD 

A  concussion  and  an  extravasation  are  very  distinct  causes  of 
mischief,  though  not  always  very  distinguishable. 

M.  Le  Dran,  and  others  of  the  modern  French  writers,  have 
made  a  very  sensible  and  just  distinction  between  that  kind  and 
degree  of  loss  of  sense  which  arises  from  a  mere  commotion  of 
the  brain,  and  that  which  is  caused  by  a  mere  extravasation,  in 
those  instances  in  which  the  time  of  the  attack  or  appearance  of 
such  symptoms  is  different  or  distinct.  The  loss  of  sense, 
which  immediately  follows  the'violence,  say  they,  is  most  probably 
owing  to  a  commotion;  but  that  which  comes  on  after  an  interval 
of  time  has  passed,  is  most  probably  caused  by  extravasation. 

This  distinction  is  certainly  just  and  good,  as  far  as  it  will  go. 
Thai  degree  of  abolition  or  diminution  of  sense,  which  immedi- 
ately attends  or  follows  the  blow  or  fall,  and  goes  off  again  without 
the  assistance  of  art,  is  in  all  probability  occasioned  by  the  sudden 
shake  or  temporary  derangement  of  the  contents  of  the  head;  and 
the  same  kind  of  symptoms  recurring  again  some  time  after  they 
had  ceased,  or  not  coming  on  until  some  time  has  passed  from 
the  receipt  of  the  violence,  do  most  probably  proceed  from  the 
breach  of  a  vessel  within  or  upon  the  brain.  Bus  unluckily  we  have 
it  not  very  often  in  our  power  to  make  this  exact  distinction.  An 
extravasation  is  often  made  so  immediately,  and  so  largely,  at  the 
instant  of  the  accident,  that  all  sense  and  motion  are  instantane- 
ously lost,  and  never  again  return  And  it  also  sometimes  hap- 
pens, that  although  an  extravasation  may  possibly  not  have  been 
made  at  the  moment  of  the  accident,  and  the  first  complaints  may 
have  been  owing  to  commotion  merely,  yet  a  quantity  of  fluid 
having  been  shed  from  its  proper  vessels  very  soon  after  the  acci- 
dent, and  producing  its  proper  symptoms,  before  ihose  caused  by 
the  commotion  have  had  time  to  go  off,  the  similarity  of  the 
effects  of  eacli^of  these  different  causes  is  such,  as  to  deprive  us 
of  all  power  of  distinguishing  between  the  one  and  the  other,  or 
of  determining  with  any  tolerable  precision  to  which  of  them 
such  symptoms  as  remain  are  really  owing. 

When  an  extravasation  of  any  kino  i-^  made,  either  upon  or 
within  the  brain,  if  it  be  in  such  quantity,  or  so  situated,  as  to 
disorder  the  economy  of  the  ariinid}.  it  always  produces  such  dis- 
order, by  making  an  unnatural  pressure  on  the  pans  where  it  lies. 


*'  FROM  EXTERNAL  VIOLENCE.  151 

Tlie  nature  and  degree  of  the  syniptoms  hereby  produced  are 
various  and  different  in  different  persons,  according  to  the  kind, 
quantity,  and  situation  of  the  pressing  fluid.  Sometimes  it  is 
mere  fluid  blood,  sometimes  blood  in  a  state  of  coagulation;  some- 
times it  is  a  clear  lymph,  and  at  others  blood  and  water  are  found 
mixed  together:  each  of  these  is  found  either  simple  or  mixed  in 
different  situations;  that  is,  between  the  scull  and  dura  mater, 
between  the  dura  and  pia  mater,  or  in  the  natural  cavities  of  the 
brain  called  its  ventricles,  and  sometimes  in  cases  of  great  vio- 
lence, they  are  found  at  the  same  time  in  all  these  different  parts. 
Sometimes  a  considerable  quantity  is  shed  instantly,  at  the  time 
of  the  accident;  and  sometimes  the  breach  by  which  the  elfiision 
is  made  is  so  circumstanced,  both  as  to  nature  and  situation,  that 
it  is  at  first  very  small,  and  increases  by  faster  or  slower  degrees. 
In  the  former,  the  symptoms  are  generally  immediate  and  urgent, 
and  the  extravasation  is  of  the  bloody  kind;  in  the  latter,  they  are 
frequently  slight  at  first,  appear  after  some  litttle  interval  of  time, 
increase  gradually  till  they  become  urgent  or  fatal,  and  are  in 
such  case  generally  occasioned  by  extravasated  lymph.  So  that 
although  the  immediate  appearance  of  bad  symptoms  does  most 
certainly  imply  mischief  of  some  kind  or  other,  yet,  on  the  other 
hand,  no  man  ought  to  suppose  his  patient  free  from  hazard,  either 
because  such  symptoms  do  not  show  themselves  at  first,  or  because 
they  appear  to  be  but  slight:  they  which  come  on  late,  or  appearing 
slight  at  first  increase  gradually,  being  full  as  much  to  be  dreaded, 
as  to  consequence,  as  the  more  immediately  alarming  ones;  with 
this  material  difference  between  them,  that  the  one  may  be  the 
consequence  of  a  mere  concussion  of  the  brain,  and  may  by 
means  of  quietude  and  evacuation  go  quite  off;  whereas,  the 
other  being  most  frequently  owing  to  an  extravasation  of  lymph 
(though  sometimes  of  blood  also)  within  the  substance  of  the 
brain,  are  very  seldom  removed  by  art. 

Extravasations  of  any  kind,  and  wherever  situated  within  the 
cranium,  are  very  hazardous,  and  much  more  irequetitly  end  fa* 
tally  than  happily;  but  considered  as  relative  to  the  art  of  surgery, 
that  'which  consists  of  merely  fluid  blood  situated  between  the 
cranium  and  dura  mater  is  certainiy  thf;  best,  as  it  is  the  nearest  to 
the  surface,  and  admits  the  greatest  probability  of  being  relieved 


153  INJURIES  OF  THE  HEAD 

by  perforation  of  the  scull:  grumousor  coagulated  blood,  although 
in  the  same  situation,  by  being  most  frequently  adhering  to  the 
membrane,  is  not  so  readily  discharged  as  the  preceding,  and 
therefore  more  likely  to  prove  destructive:  and  all  those  which 
are  either  under  the  meninges,  or  within  the  cavities  or  substance 
of  the  brain,  as  they  are  seldom  within  our  exact  knowledge,  so 
they  are  also  generally  beyond  the  reach  of  our  art. 

The  method  of  treating  people  under  these  unhappy  circum- 
stances is  somewhat  different,  according  to  the  supposed  or  most 
probable  nature  of  the  complaint,  and  according  to  the  symptoms 
and  appearances  which  it  produces,  or  which  accompany  it. 
When  the  symptoms  which  imply  a  pressure  made  on  the  brain 
or  nerves  have  been  occasioned  merely  by  a  shake  or  concussion, 
and  neither  blow  nor  other  external  violence  has  been  offered  to 
or  received  by  the  head,  we  have  no  rule  whereby  to  form  any 
other  than  a  general  opinion;  no  mark  which  can  point  out  to  us, 
either  the  precise  nature  of  the  disease,  or  its  particular  situation; 
consequently,  we  have  no  direction  from  what  part  of  the  head  to 
remove  the  scalp,  or  where  to  apply  a  perforating  instrument,  and 
therefore  no  warrant  for  perforating  at  all.  In  this  case,  the  only 
chance  of  relief  is  from  phlebotomy  and  aperients;  by  which  we 
may  hope  so  to  lessen  the  quantity  of  the  circulating  fluids,  as  to 
assist  nature  in  the  dissipation  or  absorption  of  what  has  been  ex- 
travasated.  This  is  an  effect,  which,  although  not  highly  impro- 
bable in  itself,  yet  is  not  to  be  expected  from  a  slight  or  trifling  ap- 
plication of  the  means  proposed.  The  use  of  them  must  be  pro- 
portioned to  the  hazard  of  the  case.  Blood  must  be  drawn  off 
freely  and  repeatedly,  and  from  different  veins;  the  belly  must  be 
kept  constantly  open,  the  body  quiet,  and  the  strictest  regularity 
of  general  regimen  must  be  rigidly  observed.  By  these  means,  very 
.  alarming  symptoms  have  now  and  then  been  removed,  and  people 
in  seemingly  very  hazardous  circumstances  have  been  recovered. 
Instances  of  these  successes  are  not  indeed  so  frequent  as  we  could 
wish,  but  they  have  been  sufficiently  so  to  warrant  the  attempt, 
especially  in  cases  where  there  are  no  indications  to  authorise  the 
use  of  any  other.  But  when  the  symptoms  of  extravasation  are  the 
consequence  of  such  external  violence  as  leaves  a  mark  where  it 


FROM  EXTERNAL  VIOLENCE.  153 

was  inflicted,  and  when  the  scalp  is  so  bruised  or  wounded  as  to 
shew  the  place  where,  we  then  have  some  degree  of  assistance, 
both  in  forming  a  judgment  of  the  most  probable  nature  of  the 
complaint,  and  in  using  the  means  most  likely  to  prove  successful 
in  its  relief.  For  if  the  effusion  has  been  the  consequence  of  the 
stroke  which  the  head  has  received,  and  such  effusion  is  made  im- 
mediately under  the  part  so  stricken,  the  perforation  of  the  cranium 
in  this  place  may  give  discharge  to  the  extravasated  fluid;  and  the 
wound  or  bruise  in  the  scalp  shows  us  the  point  from  whence  we 
ought  to  remove  a  portion  of  it,  in  order  to  perforate  the  cranium. 
This  I  say  is  sometimes  the  case,  and  the  consequence  is  some- 
times so  fortunaie  that  we  save  a  perishing  patient.  But,  al- 
though it  does  now  and  then  happen  that  we  succeed,  yet  such 
success  is  by  no  means  certain  or  to  be  depended  upon.  Every 
thing  relative  to  this  kind  of  disorder  is  fallible  and  uncertain;  and 
though  the  extravasation  be  sometimes  found  immediately  under 
the  external  mark,  yet  it  often  happens  that  it  is  not,  and  that  the 
effusion  is  made  in  a  part  distant  from  that  mark,  and  to  which  we 
have  nothing  to  lead  us.  Upon  the  whole,  although  a  bruise  or 
wound  of  the  scalp  does  not  in  these  cases  necessarilj  or  certainly 
point  out  the  seat  of  an  extravasation,  yet  whe«  bad  symptoms 
urge,  and  evacuation  has  been  fully  and  unsuccessfully  tried,  such 
mark  may  be  deemed  a  sufficient  though  not  unerring  authority 
for  making  farther  inquiry,  by  removing  the  scalp  and  perforating 
the  cranium:  for  this  is  a  kind  of  case  in  which  we  are  not  to  ex- 
pect certainty,  and  in  which  we  must  be  content  with  such  inform- 
ation as  we  can  obtain.  The  opportunities  which  we  have  of 
being  serviceable  are  but  few;  we  should  therefore  suffer  none  to 
escape,  but  embrace  even  possibility.  The  general  advice  given 
by  Fabritius  ab  Aquapendente^  is  applicable  to  no  part  of  surgery 
more  than  to  this;  in  which  the  loss  of  a  very  short  space  of  time 
is  often  absolutely  irretrievable. 

*  If  the  extravasation  be  of  blood,  and  that  blood  be  in  a  fluid  state, 
small  in  quantity,  and  lying  between  the  scull  and  dura  mater,  im- 

'■  "  In  vulnerib'js  qnse  natura  sua  admodum  peviculosa  sunt,  pessimura  est 
"'  expectare  prava  symptoniatii  ;  et  tunc  demum  providere,  cum  torsitan 
*'  occasio  prpeteriit,  nee  aniplius  providere  licet."      Fab,  ab  AauAFESTDESTE. 

VOL.  I.  TT 


154  INJURIES  OF  THE  HEAD 

mediately  under  or  near  to  the  place  perforated,  it  may  happily  be 
all  discharged  by  such  perforation,  and  the  patient's  life  may 
thereby  be  saved;  of  which  many  instances  are  producible.  But 
if  the  event  does  not  prove  so  fortunate,  if  the  extravasation  be  so 
large  or  so  situated  that  the  operation  proves  insufficient,  yet  the 
symptoms  having  been  urgent,  general  evacuation  having  been 
used  ineffectually,  and  a  wound  or  bruise  of  the  scalp  having 
pointed  out  the  part  which  most  probably  received  the  blow;  al- 
though the  removal  of  that  part  of  the  scalp  should  not  detect  any 
injury  done  to  the  bone,  yet  the  symptoms  still  subsisting,  I  cannot 
help  thinking,  that  perforation  of  the  cranium  is  in  these  circum- 
stances so  fully  warranted,  that  the  omission  of  it  may  truly  be 
called  a  neglect  of  having  done  that  which  might  have  proved 
serviceable,  and,  rebus  sic  stantibus,  can  do  no  harm.  It  is  very 
true,  that  no  man  can  beforehand  tell  whether  such  operation  will 
prove  beneficial  or  not,  because  he  cannot  know  the  precise  na- 
ture, degree,  or  situation  of  the  mischief;  but  this  uncertainty,  pro- 
perly considered,  is  so  far  from  being  a  dissuasive  from  the  at- 
tempt, that  it  is  really  a  strong  incitement  to  make  it;  it  being 
full  "as  impossible  to  know  that  the  extravasated  fluid  does  not 
lie  between  the  scull  and  dura  mater,  and  that  under  the  part 
stricken,  as  that  it  does;  and  if  the  latter  should  be  ihe  case,  and 
the  operation  be  not  performed,  one,  and  most  probably  the  only 
means  of  relief,  will  have  been  omitted. 

Morgagni,  in  his  book  De  Causis  et  Sedibus,  &c.  has  treated 
this  subject  expressly,  and  has  enumerated  all  the  objections  which 
may  be  made  to  the  perforation  of  the  cranium,  in  the  case  of 
effusion  of  fluid  within  it;»  but  among  others  he  has  mentioned  a 

^  "  Nam  ut  signa  sint,  ex  quibus  liceat  suspicai'i  sanguinem  intra  calvariam 
"  esse  effusiim,  quis  scire  pro  certo  possit,  an  re  vera  ;  et  si  hoc  etiam  sciret, 
"in  quam  partem  effusus  sit,  et  quod  consequitur,  ubi  et  sit  pertere'pran- 
"  dum,"  &c. 

"Nam  pretur  iinum,  qui  majorem  fortasse  exterius  dolorem  moveat,  alia 
"esse  possunt  loca,  sub  quibus  majus  reveni  lateat  internum  vitium. 

"In  cognoscendo  quam  fallaces  ssepe  sint  conjecturse,  vel  hinc  apparet, 
"  quod  et  si  pars  ipsa  icta,  ab  segro  indicatur,  imo  ecchymosi  et  tuniore  se 
"ipsam  prjeclare  indicet,  non  raro  tamen  casus  incidunt,  in  quibus  alia  pars 
"  sit  contusa,  alia  in  quam  effusio  facta  sit. 

"  Satis  jam  superque  intelligis  casus  incidere,  in  quibus  aut  nulla,  aut  tan5 


FROM  EXTERNAL  VIOLENCE.  155 

popular  one,  which  prevails  much  among  his  countrymen;  viz.  the 
fear  of  having  been  thought  to  have  destroyed  those,  whom  in  the 
nature  of  things  they  could  not  save,  "  ne  sic  occisi,  qui  servari 
"  non  potuerant,  viderentur."  With  all  possible  deference  to  so 
able  a  man,  I  must  say,  that  this  does  not  seem  to  me  to  be  by  any 
means  a  good  reason,  or  one  which  ought  to  be  formed  into  a 
maxim  for  practitioners:  it  is  founded  on  the  weakness  and  inca- 
pacity of  those  who  pretend  to  judge  of  what  they  do  not  under- 
stand, and  therefore  should  never  be  embraced  through  a  self-in- 
terested principle  by  those  who  know  better.  If  such  rule  were 
universally  admitted,  we  should  often  be  prevented  from  embrac- 
ing a  critical  opportunity,  or  using  what  in  many  cases  is  the  uni- 
cum  remedium^  not  only  in  this  disease  but  in  many  others.  The 
case  of  Ptolemy,  cited  by  him  from  Livy,  although  brought  as  a 
strong  corroboration  of  his  own  opinion,  really  can  prove  nothing, 
unless  it  could  be  made  to  prove  that  terebration  was  the  cause  of, 
or  at  least  accelerated,  the  patient's  death;  which  it  can  by  no 
means  be  made  to  do.  No  man,  who  is  at  all  acquainted  with 
this  subject,  will  ever  venture  to  pronounce  or  promise  success 
from  the  use  of  the  trephine,  even  in  the  most  apparently  slight 
cases;  he  knows  that  honestly  he  cannot:  it  is  enough  that  it  has 
often  been  successful  where  and  when  every  other  means  have 
failed.  The  true  and  just  consideration  is  this:  Does  the  opera- 
tion of  perforating  the  cranium  in  such  case  add  at  all  to  that  de- 
gree of  hazard  which  the  patient  is  in  before  it  is  performed?  or 
can  he  in  many  instances  do  well  without  it?  If  it  does  add  to  the 
patient's  hazard,  that  is  certainly  a  very  good  reason  for  laying  it 
aside,  or  for  using  it  very  cautiously;  but  if  it  does  not,  (which  I 
verily  believe,)  and  the  only  objection  made  to  it  is,  that  it  fre- 
quently fails  of  being  successful,  surely  it  cannot  be  right  to  disuse 
that  which  has  often  been  not  only  salutary,  but  the  causa  sine  qua 
non  of  preservation,  merely  because  it  is  also  often  unsuccessful; 
that  is,  because  it  is  not  infallible. 

* 
"  ]evia,  inter  Initia  se  offerunt,  efFusi  intra  cranium  sanguinis  signa,  tot  autem, 
"  et  tam  gru%'ia  post  lorigum  intervallum  confestim  se  ingerunt,  ut  neque 
"  primo  illo  opportune  tempore  seger  ex  timore  periculi,  ut  terebram  admit. 
"  tat,  neque  extremo  sperare  possent  medici,  opem  se  per  earn  allaturos,  tam 
"  longo  spatio  et  tam  perniciosis  indiciis  extantibus." 

MoKGAGSi  ite  Caitsis  et  Sed.  Morbor. 


156  ,  INJURIES  OF  THE  HEAD 

I  should  be  extremely  sorry  to  say  any  thing  which  might  mis- 
lead my  reader,  but  I  cannot  help  thinking,  that,  dark  and  obscure 
as  this  part  of  surgery  is,  yet  there  are  sometimes  appearances  and 
circumstances,  which  maybe  said  positively  to  indicate  the  fitness 
of  the  operation,  among  which  I  reckon  the  spontaneous  detach- 
ment of  the  pericranium  from  the  scull,  in  consequence  of  a  heavy 
blow,  attended  with  symptoms  of  stupefaction  or  loss  of  sense. 

Whenever  the  dura  mater  is  separated  from  its  attachment  to 
the  inner  surface  of  the  cranium,  the  pericranium  covering  the 
outer  part  of  the  same  bone  is  generally  detached  also.  When  this 
separation  is  produced  by  the  formation  of  matter,  in  consequence 
of  inflammalion,  the  tumefaction  of  the  scalp,  which  denotes  this 
effect,  appears  some  days  after  the  violence  has  been  received,  and 
is  always  accompanied  with  a  symptomatic  fever.  The  effusion 
of  a  considerable  quantity  of  estravasated  blood  on  the  surface  of 
the  dura  mater,  as  it  absolutely  separates  that  membrane  from  the 
bone,  and  cuts  off  all  communication  between  that  part  and  the 
scalp,  so  it  does  in  the  same  manner  oblige  the  pericranium  to 
quit  its  attachment  to  the  scull,  of  which  I  have  remarked  fre- 
quent instances,  and  I  have  also  most  frequently  observed,  that 
the  blood  in  such  cases  has  been  coagulated,  and  very  adherent 
to  the  membrane.  Now  if  this  observation  should  be  found  to  be 
most  frequently  true,  that  is,  if  a  detachment  of  the  dura  mater 
from  within  the  scull,  by  means  of  an  extravasation,  be  found  to 
be  most  frequently  accompanied  by  a  detachment  of  the  pericra- 
nium on  the  outside,  have  we  not  thereby  an  indication  both  why 
and  where  we  ought  to  perforate?  The  operation  may  not  be  suc- 
cessful, but  desperation  cannot  be  submitted  to  while  there  is  the 
most  extreme  degree  of  probability  of  being  serviceable. 

A  free  discharge  by  means  of  it  may  produce  a  cure,  or  it  may 
prove  only  a  temporary  relief,  according  to  the  different  circum- 
stances of  different  cases:  the  disappearance  or  even  the  allevia- 
tion of  the  most  pressing  symptoms  is  undoubtedly  a  favourable 
circumstance,  but  is  not  to  be  depended  tipon  as  absolutely  por- 
tending a  good  event;  either  a  bloody  or  limpid  extravasation  may 
be  formed  or  forming  between  the  meninges,  or  upon  or  within 
the  brain,  and  may  prove  as  certainly  pernicious  in  future  as  the 
more  external  effusion  would  have  done  had  it  not  been  dis- 


FROM  EXTKRNAL  VIOLENCE.  l.'i'V 

eharged;  or  the  dura  mater  may  have  been  so  damaged  by  the  vio- 
lence of  the  blow  as  to  inflame  and  suppurate,  and  thereby  destroy 
the  patient.  The  complaints  arising  from  extravasation,  and  from 
suppuration,  are  (as  I  have  already  at  large  observed)  very  diifer- 
ent  and  distinct  from  each  other;  the  former  may  be  relieved,  or 
even  totally  removed,  and  the  latter  not  prevented,  nor  indeed  be 
capable  of  prevention:  of  this  every  practitioner  should  be  aware, 
lest  he  expect  and  promise  too  much. 

The  nearer  the  extravasated  fluid  lies  to  the  cranium  the  better; 
therefore,  that  which  is  situated  between  the  scull  and  dura  mater 
is,  caeteris  paribus,  the  most  favourable  of  any.  If  the  disease 
lies  between  the  dura  and  pia  mater,  mere  perforation  of  the  scull 
can  do  nothing;  and  therefore,  if  the  symptoms  are  pressing,  there 
is  no  remedy  but  division  of  the  outer  of  these  membranes.  The 
division  of  the  dura  mater  is  an  operation  which  I  have  several 
times  seen  done  by  others,  and  have  often  done  myself;  I  have 
seen  it,  and  have  found  it  now  and  then  successful;  and  from  those 
instances  of  success,  am  satisfied  of  the  propriety  and  necessity  of 
its  being  sometimes  done:  but  let  not  the  practitioner,  who  has  not 
had  frequent  opportunity  of  seeing  these  kinds  of  things,  presume, 
from  the  light  manner  in  which  this  necessary  operation  has  been 
spoken  of  by  a  few  modern  writers,  that  it  is  a  thing  of  little  con; 
sequence;  for  it  most  certainly  is  not.  Wounds  of  the  membranes 
of  the  brain,  by  whatever  body  inJlicted,  or  in  whatever  manner 
made,  have  always  been  deemed,  and  (which  is  more  to  the  purpose) 
have  always  been  found  to  be  hazardous.  There  is  indeed  some 
difference  between  a  wound  made  by  a  clean  lancet  or  knife,  and 
one  made  by  bone,  bullet,  or  any  thing  which  bruises  or  tears:  but 
this  relates  only  to  the  manner :  the  part  wounded  is  the  same  in 
all;  and  whether  the  dura  mater  be  divided  by  a  lancet,  or  by  a 
fragment  of  bone,  or  any  other  body,  it  is  equally  divided,  and  the 
air  is  let  in  in  the  same  manner  on  the  pia  mater,  or  brain,  which 
become  thereby  subject  to  all  the  ills  which  such  wound,  or  such 
exposition,  is  capable  of  causing. 

Authors,  indeed,  do  every  now  and  then  tell  us  strange  stories, 
and  give  us  strange  accounts  of  incisions  made  into  the  meninges 
and  brain  in  search  of  foreign  bodies,  of  extravasated  fluids,  &:c. : 
but  let  the  young  practitioner  read  these  relations  with  ^ome  re- 


158  INJURIES  OF  THE  HEAD 

serve  of  faith,  and  recollect  that  the  excellent  advice  given  by  a 
very  able  man,  "  Homines  non  admiratione  afficere,  sed  eis  utiliora 
"  docere,"  is  not  always  attended  to  by  writers.  Caution  and 
fear  are  different  things;  where  any  good  can  be  done,  it  ought  to 
be  attempted  by  every  practicable  and  justifiable  means;  but 
where  no  good  is  reasonably  to  be  expected,  there  is  no  warrant 
for  doing  any  thing.  The  division  of  the  dura  mater  I  have  seen 
to  be  necessary,  and  I  have  seen  it  to  be  successful:  but  all 
wounds  of  it  are  far  from  being  matters  of  indiflerence.  Every 
chance  of  life  is  to  be  embraced,  and  a  good  surgeon  will  never 
hesitate  to  execute  whatever  appears  feasible,  or  even  possibly 
beneficial ;  but  at  the  same  time  he  will  not  act  without  some 
such  kind  of  warranty  as  shall  prove  that  his  patient's  benefit  was 
his  one  object,  and  will  take  care  that  neither  his  prognostic  nor 
his  conduct  shall  expose  him  justly  to  the  censure  of  being  either 
ignorant,  unfeeling,  or  fool-hardy. 

Upon  the  removal  of  a  piece  of  bone  by  means  of  the  trephine, 
if  the  operation  shall  have  been  performed  over  the  part  where 
the  disease  is  situated,  and  the  extravasation  be  of  the  fluid  kind, 
and  between  the  cranium  and  dura  mater,  such  fluid-,  whether  it 
be  blood,  w^ater,  or  bolh,  is  immediately  seen,  and  is  partly  dis- 
charged by  such  opening:  if,  on  the  other  hand,  the  extravasation 
be  of  blood  in  a  coagulated  or  grumous  state,  it  is  either  loose,  or 
in  some  degree  adherent  to  the  dura  mater:  if  the  former  of  these 
be  the  case,  it  is  either  totally  or  partially  discharged  at  the  time 
of  or  soon  after  the  operation,  according  to  the  quantity  or  extent 
of  the  mischief :  if  the  latter,  the  perforation  discovers,  but  does 
not  immediately  discharge  it.  In  both  instances,  the  conduct  of 
the  surgeon,  with  regard  to  repetition  of  the  operation,  must  be 
determined  by  the  particular  circumstances  of  each  individual 
case;  a  large  extravasation  must  necessarily  require  a  more  free  re- 
moval of  bone  than  a  small  one;  not  only  on  account  of  freedom 
of  discharge,  but  on  account  of  larger  detachment  of  dura  mater; 
and  a  grumous  or  coagulated  extravasation  requires  a  still  more 
free  use  of  the  instrument,  not  only  because  the  blood  in  such  stale 
is  discharged  with  difficulty,  but  because  the  whole  surface  of  the 
dura  mater  so  covered  is  always  put  under  the  necessity  of  sup- 


PROM  EXTERNAL  VIOLENCE.  150 

purating,  which  suppuration  has  but  one  chance  of  a  happj'  event, 
and  that  derivable  from  the  free  use  of  the  perforator. 

When  the  extravasation  is  not  between  the  cranium  aud  dura 
mater,  but  either  between  the  meninges,  or  in  the  ventricles  of 
the  brain,  the  appearances  are  not  only  different  from  the  pre- 
ceding state  of  the  case,  but  from  each  other. 

When  the  extravasated  fluid  lies  between  the  scull  and  dura 
mater,  as  soon  as  that  extravasation  is  discharged,  or  the  grumous 
blood  has  been  wiped  off,  ihe  dura  mater  appears  flaccid,  easily 
yields  to  or  does  not  resist  the  impression  of  a  finger,  and  (the 
discharge  being  made)  enjoys  that  kind  of  motion,  that  elevation 
and  depression,  which  our  fathers  supposed  it  to  have  naturally 
and  always,  but  which  is  only  the  consequence  of  the  circulation 
through  the  brain,  and  the  artificial  removal  of  the  piece  of  bone. 
But  when  the  extravasation  is  situated  between  the  meninges,  or 
on  the  surface  of  the  brain,  the  appearance  is  not  the  same.  In 
this  case,  there  is  no  discharge  upon  removing  the  bone;  and  the 
dura  mater,  instead  of  being  flaccid  and  readily  obeying  the  mo- 
tion of  the  blood,  appears  full  and  turgid,  has  little  or  no  motion, 
and  pressing  hard  against  the  edges  of  the  perforation,  rises  into  a 
kind  of  spheroidal  form  in  the  whole  of  the  perforated  bone.  If 
the  extravasation  be  of  the  limpid  kind,  the  membrane  retains  its 
natural  colour;  but  if  it  be  either  purely  fluid  blood,  or  blood  co- 
agulated, and  the  subject  young,  the  colour  of  the  membrane  is  so 
altered  by  what  lies  under  it,  that  the  nature  of  the  case  is  always 
determinable  from  this  circumstance. 

Be  the  extravasated  fluid  what  it  may,  it  has  no  natural  outlet; 
absorption  was  the  only  chance  the  patient  had  whereby  to  get 
rid  of  it  without  an  operation,  and  that  we  must  now  suppose  to 
have  failed;  an  artificial  opening  therefore  must  be  made,  by  the 
division  of  the  dura  mater,  and  perhaps  of  the  pia  also.  This 
operation,  under  the  circumstances  and  appearances  already  men- 
tioned, is  absolutely  necessary,  and  has  been  successful:  it  is  per- 
formed to  give  discharge  to  what  cannot  be  got  rid  of  by  any 
other  means,  and  consists  in  a  division  of  the  membrane  or  mem- 
branes, made  in  a  crucial  form  with  a  point  of  a  lancet.  The 
operation  in  itself  is  extremely  simple  and  easy,  but  the  patient  is 
thereby  put  into  the  state  of  one  whose  meninges  have  been 


160  INJURIES  OF  THE  HEAD 

wounded,  with  only  this  difference,  that  the  wound  made  for  this 
purpose  is  smooth  and  simple,  and  inflicted  with  the  least  possi- 
ble violence;  whereas  an  accidental  wound  of  the  same  parts 
may  be  lacerated,  contused,  and  attended  with  circumstances 
which  must  aggravate  the  evil,  and  may  induce  worse  conse- 
quences. 


Of  commotion  or  concussion  of  the  solid  parts  of  the  brain,  we 
have  only  a  negative  kind  of  proof,  and  therefore  are  still  more  in 
the  dark,  than  we  are  with  regard  to  extravasation. 

Yery  alarming  symptoms,  followed  sometimes  by  the  most  fatal 
consequences,  are  found  to  attend  great  violences  offered  to  the 
head;  and  upon  the  strictest  examination  both  of  the  living  and 
the  dead,  neither  fissure,  fracture,  nor  extravasation  of  any  kind, 
can  be  discovered.  The  same  symptoms,  and  the  same  event, 
are  met  with  when  the  head  has  received  no  injury  at  all  ab  ex- 
terno^  but  has  only  been  violently  shaken;  nay,  when  only  the 
body  or  general  frame  has  seemed  to  have  sustained  the  whole 
violence.  It  is  a  commonly  received  opinion,  that  a  concussion 
of  the  brain  is  always  in  proportion  to  the  resistance  which  the 
cranium  makes;  that  if  the  latter  sustains  a  considerable  degree 
of  fracture,  the  former  is  but  slightly  injured,  and  that  the  con- 
cussion  is  greatest  when  the  scull  is  least  hurt.  This  may  some- 
times be  the  case;  violent  and  even  fatal  commotions  of  the  brain 
happen  when  no  injury  has  been  done  to  the  scull,  and  very  large 
and  terrible  fractures  are  sometimes  unattended  with  any  symp- 
toms of  concussion;  all  this  is  sometimes  true,  but  the  position 
can  by  no  means  be  admitted  as  a  general  principle,  whereon  to 
form  our  judgment,  or  whereby  to  regulate  our  conduct;  experi- 
ence frequently  contradicting  it. 

The  symptoms  attending  a  concussion  are  generally  in  propor- 
tion to  the  degree  of  violence  which  the  brain  itself  has  sustain- 
ed, and  which  indeed  is  cognizable  only  by  the  symptoms.  If 
the  concussion  be  very  great,  all  sense  and  power  of  motion  are 
immediately  abolished,  and  death  follows  soon:  but  between  this 
degree  and  that  slight  confusion  (or  stunning,  as  it  is  called) 
which  attends  most  violences  done  to  the  head,  there  are  many 
stages.      Sometimes  a  concussion  produces  the  same  kind  of 


FIIOM  EXTERNAL  VIOLENCE.  161 

oppressive  symptoms  as  an  extravasation,  and  the  patient  is  either 
almost  or  totally  bereft  of  sense:  at  other  times  no  such  symploms 
attend,  but  the  patient  gets  no  sleep  at  all,  has  a  wild  loolc,  an 
eye  much  like  to  that  of  a  person  who  has  long  watched  through 
apprehension  and  anxiety,  talks  much  and  very  inconsistently, 
has  a  hard  labouring  pulse,  some  small  degree  of  fever,  and 
sometimes  an  inclination  to  vomit:  if  not  retained,  the  patient 
will  get  out  of  bed,  and  act  with  a  kind  of  frantic  absurdity, 
and  appears  in  general  much  hurt  by  a  strong  light.  A  de- 
bility of  understanding,  an  ideot  look,  a  failure  of  memory,  a 
paralytic  affection  of  some  one  part  or  limb,  the  loss  of  sense, 
spasm,  resolution  or  rigidity  of  some  one  part  or  muscle,  are 
often  the  consequence  of  it.  These  complaints  are  sometimes 
cured,  but  some  of  them  do  sometimes  remain  through  the  rest 
of  life. 

To  distinguish  bet^yeen  an  extravasation  and  a  commotion  by 
the  symptoms  only,  is  frequently  a  very  difficult  matter,  some- 
times an  impossible  one.  The  similarity  of  the  effects  in  some 
cases,  and  the  very  small  space  of  time  which  may  intervene  be- 
tween the  going  off  of  the  one  and  accession  of  the  other,  render 
this  a  very  nice  exercise  of  the  judgment.  The  first  stunning  or 
deprivation  of  sense,  whether  total  or  partial,  may  be  from  either; 
and  no  man  can  tell  from  which.  But  when  these  first  symptoms 
have  been  removed,  or  have  spontaneously  disappeared;  if  such 
^tient  is  again  oppressed  with  drowsiness,  or  stupidity,  or  total 
or  partial  loss  of  sense,  it  then  becomes  most  probable  that  the 
first  complaints  were  from  commotion,  and  that  the  latter  are  from 
extravasation;  and  the  greater  the  distance  of  time  between  the 
two,  the  greater  is  the  probability  not  only  that  an  extravasation  is 
the  cause,  but  that  the  extravasation  is  of  the  limpid  kind,  made 
gradatim,  and  within  the  brain. 

Whoever  seriously  reflects  on  the  nature  of  these  two  causes  of 
evil  within  the  cranium,  and  considers  them  as  liable  to  frequent 
combination  in  the  same  subject,  and  at  the  same  time  considers, 
that  in  many  instances  no  degree  of  information  can  be  obtained 
from  the  only  person  capable  of  giving  it,  (the  patient,)  will  im- 
mediately be  sensible,  how  very  difficult  a  part  a  practitioner  has 
to  act  in  many  of  these  cases,  and  how  very  unjust  it  must  be  tc 

VOL.  I.  X 


162  INJURIES  OF  THE  HEAD 

call  that  ignorance,  which  is  only  a  just  diffidence  arising  from  tb^ 
obscurity  of  the  subject,  and  the  impossibility  of  attaining  materials 
to  form  a  clear  judgment. 

When  there  is  no  reason  to  apprehend  any  other  injury,  and 
commotion  seems  to  be  the  sole  disease,  plentiful  evacuation  by 
phlebotomy  and  lenient  cathartics,  a  dark  room,  the  most  perfect 
quietude,  and  a  very  low  regimen,  are  the  only  means  in  our 
power;  and  are  sometimes  successful. 

Having  in  the  preceding  sheets  frequently  spoken  of  the  tre- 
phine, I  have  only  to  add,  that  if  such  operation  be  attended  with 
success,  that  is,  if  an  extravasated  fluid  be  thereby  discharged,  a 
depressed  bone  elevated,  matter  which  had  been  formed  between 
the  scull  and  dura  mater  let  out,  or  the  inflammatory  tension  of 
the  membrane  prevented,  in  such  manner  as  to  rescue  the  patient 
from  the  danger  he  was  in  from  such  accident;  in  such  cases,  I 
say,  that  the  bare  dura  mater  readily  obeys  the  motion  of  the. 
blood  through  the  brain,  and  is  freely  elevated  and  depressed;  by 
degrees  it  loses  its  bright  silver  hue,  and  becomes  purulent  and 
sloughy,  and  then  casting  off  this  slough,  is  covered  by  a  granu- 
lation of  new  flesh,  of  firm  consistence  and  florid  red  colour; 
moderate  quantity  of  good  matter  is  discharged  daily,  and  the 
new  incarnation  rises  gradually  through  the  perforation,  until 
it  gets  above  the  edges  of  it,  when  joining  with  that  which 
either  has  sprung  from  the  surface  of  the  bare  cranium,  or 
which  has  thrown  ofl"  from  thence  a  small  exfoliation,  they 
together  make  a  firm  cicatrix.  During  all  this  time  the  patient 
is  generally  free  from  fever  or  pain,  gets  good  sleep,  has  a 
natural  appetite,  and  seems  as  near  to  being  in  health  as  his  cir- 
cumstances can  permit. 

On  the  other  hand,  if  the  mischief  be  such  that  all  means  prove 
ineffectual,  the  appearances  are  very  diflerent.  The  dura  mater, 
instead  of  casting  otf  a  thin  slough  and  incarning  kindly,  becomes 
hard,  tense,  and  foul;  in  a  fevsr  days  it  generally  thrusts  up  an  ill- 
natured  fungus,  which,  pressing  hard  against  the  edges  of  the  per- 
foration, prevents  the  discharge  fiom  within;  the  bare  bone  be- 
comes blackish  or  deeply  yeilou',  and  the  edges  of  the  sore  in  the 
scalp  are  painful,  loose,  flabby,  and  have  no  connexion  with  the 
bone  on  which  they  lie;  the  discharge  is  a  thin  stinking  gleet,  and 


FROM   EXTERNAL  VIOLENCE,  163 

large  in  quantity;  the  patient  is  hot,  thirsty,  and  sleepless;  the 
tongue  is  black,  the  pulse  hard  and  quick;  sometimes  a  delirium, 
and  sometimes  frequent  spasms  disorder  and  shake  his  whole  frame; 
his  countenance  is  flushed  and  has  a  yellow  tint,  his  eyes  lose  all 
their  natural  brightness  and  seem  sunk  in  their  orbits;  and  his 
rigors,  which  were  at  first  slight  and  few,  become  more  frequent 
and  more  severe  as  his  dissolution  approaches.  A  slight  degree  of 
these  symptoms  is  sometimes  got  the  better  of  by  proper  care  and 
treatment;  but  if  they  are  far  advanced,  or  run  very  high,  we  may 
use  the  words  of  a  very  excellent  writer  on  this  subject,  I  mean 
Berengarius  Carpensis:''  Hie  casus  est  de  his ^  equibusnon  evadunt 
aliquij  nisi  nutu  dei. 

•>  The  sentiments  of  a  very  ancient  writer  on  this  matter  are  so  very  jast 
and  apposite,  that  I  hope  the  reader  will  excuse  the  length  of  the  quotation. 

"  Qui  sanescere  possunt,  vel  peinturi  sunt,  ex  his  conjicere  est;  plurimum 
"  quidem  ex  ipso  vulnere,  deinde  ct  ex  reliquo  corpore. 

"  Salubriter  se  habentium  notae.  sunt,  ulcus  non  dolens,  cerebdque  mem- 
"  brana  naturalem  colorem,  ac  motum  servans,  et  ulcus  post  suppurationem 
"  imminui.  Pus  album,  sequale,  modice  crassum,  non  male  olens.  Ulcus  quod 
"  initio  album  apparuit,  post  aliquodterapus  vubescere,  carnem  milio  similem 
"  producere,  sqiiamulasque  suis  temporibus  emittere  ;  sine  perturbatione 
"  somnum  capere  ;  sine  febre  esse  ;  cibum  appetere  ;  assumpta  digerere  ; 
"  eequas  excretiones  fieri;  glandulas,  quse  primis  die!)us  apparuerant,  aut 
"  erysipelas  cito  dissolvi. 

"Eos  qui  periclitantur  cognoscere  licet  turn  aspectu,  turn  ex  lis  qua 
"  vulneri  cjeteroque  corpori  accidunt,  et  iis  quae  excernuntur.  Color  igitur 
"  plerumque  languidus  et  permanens,  periculosus,  oculique  concavi  et  ex- 
"  tantes,  Sec.  Ulcus  dolere,  magis  interdiu,  retorridum  fieri,  atque  omni  ple- 
■"  rumque  tumore  carere,  vel  saniem  manuai-e  tenuem  ac  male  olentem  ; 
"  orasque  sectae  carnis  admodum  rubras  et  flaccidas  esse,  atque  ubi  magis 
"  reflexee  sint,  tunc  abscedere  cutem  ab  osse  molestum  est,  membranamque 
"  vulneratam  immobilem  esse,  exalbidam  vel  lividam  apparere,  vel  nigram, 
"  vel  plurimum  inflammatum  aut  procidentem,  purgatamque,  iterum  sponte 
•'  non  ob  aliqua  re  externa  sordcscere." 

Oribasius  De  Si^nis. 

"  Spem  vero  certain  faclunt,  membrana  mobilis  ac  sui  coloris,  caro  in- 
"crescens  rubicunda,  facilis  motus  maxillEe,  atque  cervicis. 

"  Mala  signa  sunt  membrana  immobilis,  nigra  vel  livida,  vel  aliter  coloris 
"  corrupli,  dementia,  acris  vomllus,  nervorum  distensio  vel  resolutio. — Caro 
"livida,  maxillarum  atque  cervicis  rigor." 

Cf-tscs. 


164  INJURIES  OF  THE  HEAI* 


CASE  XXXIII. 

A  YOUNG  fellow,  about  twenty-four  years  old,  was  thrown  by 
the  swing  of  a  crane  at  the  water-side  from  a  window  two  stories 
high,  and  pitched  his  head  on  a  sugar  hogshead.  He  was  taken 
up  senseless,  and  brought  in  that  state  to  St.  Bartholomew's  hos- 
pital- 
He  was  immediately  let  blood  freely,  and  his  head  being  first 
clean  shaved,  was  very  carefully  examined,  but  no  external  mark 
of  violence  was  found.  Next  morning  he  was  bled  again,  and  the 
same  operation  was  repeated  in  the  evening  of  that  day,  and  twice 
in  the  course  of  the  third.  On  the  fourth  day  both  the  temporal 
arteries  were  opened,  and  bled  freely.  On  the  fifth  day  he  died, 
his  symptoms  not  having  remitted  in  the  smallest  degree.  The 
cranium  was  perfectly  uninjured.  The  dura  mater  every  where 
adherent,  and  no  fluid  of  any  kind  between  it  and  the  scull.  Be- 
tween the  dura  and  pia  mater  was  a  considerable  quantity  of  fluid 
blood,  and  principally  toward  the  lower  part  of  the  brain, 

CASE  XXXiV. 

A  HACKNEY  coachman  was  thrown  from  his  box  in  Holborn, 
and  fell  on  his  head,  as  it  was  thought.  He  became  immediately 
insensible,  and  was  brought  so  to  the  hospital.  No  mark  of  vio- 
lence was  to  be  found  on  any  part  of  his  head,  and  therefore,  al- 
though his  symptoms  were  such  as  rendered  an  extravasation 
most  probable,  yet  there  was  no  reason  for  setting  on  the  instru- 
ment on  any  particular  part.  Every  thing  was  done  for  him,  both 
by  the  physician  and  myself,  from  which  any  advantage  might 
reasonably  be  expected;  but  on  the  third  day  he  expired,  having 
never  showed  any  signs  of  sense. 

All  the  space  between  the  frontal  bone  and  the  dura  mater  was 
covered  with  grumous  blood,  firmly  adherent  to  the  latter. 


FROM  EXTERNAL  VIOLENCE.  165 


CASE  XXXV. 

A  bricklayer's  labourer  fell  from  a  high  scaffold,  broke  one 
arm  and  one  thigh,  and  was  brought  to  the  hospital  about  two 
hours  afterward  in  a  state  of  stupidity.  When  his  arm  and  thigh 
were  put  to  rights,  his  head  was  examined,  but  no  mark  of  mis- 
chief discovered.  He  was  bled  freely,  and  stools  procured  on 
each  day  for  four  successive  days:  but  he  continued  in  the  same 
state.  On  the  fifth  a  small  tumor  arose  on  the  right  side  of  his 
head.  The  scalp  was  removed,  and  the  bone  being  found  bare, 
it  was  immediately  perforated.  The  perforation  made  way  for  a 
large  discharge  of  blood  which  had  been  contained  between  the 
dura  mater  and  scull.  On  the  first  and  second  day  from  this  ope- 
ration he  remained  the  same;  blood  was  drawn  from  some  part  of 
him  on  each,  and  the  discharge  continued  large  and  free  through 
the  opening  made  in  the  bone.  On  the  third  day  from  the  appli- 
cation of  the  trephine,  he  became  toward  evening  somewhat  sensi- 
ble. On  the  fourth,  having  taken  a  laxative  medicine,  he  had  a 
smart  purging,  which  lasted  some  hours.  On  the  sixth  he  was 
quite  calm  and  sensible,  but  being  reduced  to  a  very  low  state  by 
his  free  and  frequent  evacuations,  it  was  thought  right  to  give  him 
the  cortex.  This  agreed  well  with  him,  and  from  this  time  he  had 
no  other  difficulty  or  trouble. 


CASE  XXXVI. 

A  BOY,  about  ten  years  old,  climbing  up  a  ladder,  which  was 
set  too  perpendicularly,  fell  from  an  height  of  more  than  twenty 
feet;  he  lay  some  time  before  he  was  found,  and  then  was  carried 
home  perfectly  void  of  sense.  In  about  three  hours  after  the  ac- 
cident I  saw  him.  He  lay  quite  stupid  and  senseless,  now  and 
then  vomited,  had  a  hard,  full,  labouring  pulse,  and  an  obstructed 
respiration.  No  mark  of  violence  appeared  on  his  head.  He  was 
bled  freely,  and  had  a  stimulating  clyster,  which  procured  a  free 
discharge.     During  three  days  he  was  let  blood  twice  a  day;  on 


166  INJURIES  OF  THE  HEAD 

the  fourth,  a  small  degree  of  tumefaction  appeared  on  the  right 
side  of  his  head  near  to  the  sagittal  suture;  it  was  not  very  mani- 
fest, neither  did  it  appear  to  contain  any  considerable  quantity  of 
fluid,  but  the  very  desperate  circumstances  the  child  was  in,  in- 
duced me  to  open  it,  and,  finding  the  scull  bare,  to  perforate. 
The  dura  mater  was  covered  with  blood,  which  discharged  freely 
both  at  the  time  of  the  operation,  and  during  all  the  next  day.  On 
the  third  day  from  the  operation,  he  was  still  insensible.  A  se- 
cond perforation  was  made  just  below  the  first,  and  a  third  on  the 
other  side  of  the  suture.  Blood  was  discharged  freely  from  all 
three.  He  was  dressed  lightly,  and  his  pulse  being  still  strong, 
more  blood  was  drawn  from  one  of  the  jugulars.  The  next  day 
he  was  rather  better,  but  far  from  sensible.  The  day  following 
that  he  recovered  his  understanding,  and  could  make  signs  for 
what  he  wanted.  It  was  near  a  week  more  before  he  got  his 
speech,  but  in  the  end  he  got  perfectly  well. 

CASE  XXXVII. 

-  A  BOY  between  three  and  four  years  old,  the  son  of  a  merchant 
in  my  neighbourhood,  was  at  play  with  his  brother  on  a  bed,  and 
fell  from  thence  on  a  soft  bedside  carpet.  He  pitched  on  his  head, 
and  complained  immediately  of  being  sick  and  giddy,  but  having 
vomited,  was  soon  after  so  well  that  no  farther  notice  was  taken 
of  his  fall.  On  the  fourth  day  from  this,  his  sickness  and  giddi- 
ness returned.  Dr.  Lee  was  sent  for,  who,  not  regarding  the  fall 
as  having  any  share  in  his  complaint,  gave  him  an  emetic,  and  or- 
dered him  some  of  those  medicines  which  are  called  nervous.  For 
the  space  of  five  days  from  this  time,  he  continued  to  be  now  and 
then  sick  and  giddy,  and  was  very  unwilling  to  stir,  or  be  stirred. 
On  the  eleventh  he  complained  that  he  could  not  see,  and  that 
evening  had  a  sort  of  fit.  On  the  thirteenth  his  right  arm  be- 
came useless.  On  the  fifteenth  he  could  not  stand.  From  this 
evening  he  became  stupid;  and  on  the  eighteenth  expired. 

Between  the  dura  and  pia  mater  was  a  considerable  quantity 
of  bloody  serum  about  the  basis  of  the  brain. 


PROM  EXTERNAL  VIOLENCE.  167 


CASE  XXXVIII. 


A  WOMAN  came  to  my  house,  complaining  that  her  husband  had 
kicked  her  down  stairs,  and  had  broke  her  scull.  On  the  back 
part  of  her  head  was  a  small  wound,  but  the  pericranium  was  not 
divided,  nor  was  there  any  reason  to  suppose  the  bone  to  be  hurt. 
For  twelve  days  she  remained  without  any  general  complaint;  but 
on  the  thirteenth  she  began  to  be  giddy  and  dim-sighted, 

I  took  her  into  the  hospital,  where  she  was  taken  all  possible 
care  of;  but  she  became  first  paralytic,  and  then  comatose,  and  so 
died.  The  ventricles  of  the  brain  were  full  of  extravasated  serum, 
and,  near  the  origin  of  the  medulla  oblongata,  was  a  large  lump  of 
firmly  coagulated  blood. 


CASE  XXXIX. 

A  carpenter's  labourer  in  Blackfriars  fell  from  a  scaffold  of  a 
considerable  height,  and  in  his  way  down  struck  a  piece  of  tim- 
ber, which,  following  him,  hit  him  on  the  head.  The  man  fell  on 
his  breech.  He  was  brought  to  the  hospital  senseless.  The  mark 
on  his  head  made  by  the  timber  was  scarcely  visible,  and  did  not 
imply  any  mischief  underneath.  He  was  freely  let  blood,  and  his 
body  emptied  by  a  clyster  administered  that  day.  The  next  day 
more  blood  was  drawn  from  one  jugular;  and  the  third  the  same 
operation  repeated.  On  the  fourth  he  spake,  and  on  the  fifth  was 
so  sensible  as  to  give  an  account  of  the  place  from  whence  he  fell. 
On  the  sixth,  seventh,  eighth,  ninth,  tenth,  and  eleventh,  he  was 
free  from  complaint,  except  on  the  two  last  he  was  too  much  in- 
clined to  dose.  On  the  twelfth  he  found  some  difficulty  in  pro- 
nunciation, and  said,  that  it  was  with  great  difficulty  that  he  could 
keep  himself  awake.  As  his  pulse  would  very  well  bear  it,  more 
blood  was  drawn  away  by  opening  the  temporal  artery,  and  a  blis- 
ter was  applied  to  his  neck.  On  the  fifteenth  he  could  hardly 
speak  at  all,  and  was  never  awake  unless  disturbed  for  that  pur- 
pose. On  the  eighteenth  he  lost  the  use  of  his  left  side,  and  on 
the  twentieth  died. 


168  INJURIES  OF  THE  HEAD 

About  the  lower  part  of  the  brain  was  found  a  small  quantity 
of  bloody  serum,  and  all  the  ventricles  were  filled  with  a  clear 
lymph. 


CASE  XL. 

A  BOY  about  fifteen  was  thrown  over  the  head  of  a  horse,  who 
fell  down  with  him  in  Smithfield.  There  was  on  the  side  of  his 
head  a  large  wound,  with  a  bare  parietal  bone;  and  although  there 
was  no  appearance  of  fracture,  yet  the  violence  having  been  great, 
and  the  boy  being  perfectly  stupid,  I  immediately  perforated  the 
bare  bone,  suspecting  an  extravasation  on  the  dura  mater.  That 
membrane  was  perfectly  fair  and  adherent,  nor  was  there  any 
appearance  of  extravasation  either  upon  or  under  it.  The  next 
day  he  was  still  insensible.  I  examined  the  membrane  again 
very  carefully,  in  order  to  see  whether  there  was  any  sufficient 
reason  for  dividing  it,  but  could  find  none.  Blood  was  drawn 
from  different  parts  in  large  quantity,  but  to  no  purpose;  he  lived 
three  days  as  it  were  in  a  deep  sleep,  and  then  died.  There  was 
no  injury  done  to  the  scull;  no  extravasation  of  either  blood  or 
serum,  either  upon  or  between  the  membranes,  nor  any  unnatural 
appearances  in  the  cavities  of  the  brain:  but  upon  the  plexus  cho- 
roides  was  a  lump  of  coagulated  blood,  near  as  big  as  half  a  small 
chesnut. 


In  the  course  of  these  papers  I  have  more  than  once  said,  that 
although  the  symptoms  arising  from  pressure  made  on  the  brain 
and  nerves,  or  on  the  meninges,  were  uniform  and  clear,  and  per- 
fectly distinct  from  those  caused  by  inflammation,  yet  that  they 
very  seldom  indicate  what  kind  of  bodv  such  pressure  was  made 
by;  whether  blood,  water,  or  bone;  and  consequently,  that  though 
the  disorders  proceeding  from  pressure  were  perfectly  distinguish- 
able from  those  caused  by  inflammation,  yet  they  were  not  at  ail 
or  very  seldom  so  with  regard  to  each  other.  Some  of  the  imme- 
diately preceding  cases  are  proofs  with  regard  to  blood  and  lymph. 


PROM  EXTERNAL  VIOLENCE.  169 

and  what  follow  will,  I  think,  in  some  degree,  prove  that  the  symp- 
toms are  the  same  when  they  are  caused  by  bone,  or  by  blood  and 
bone  together. 


CASE  SLL 

A  CHILD  about  nine  years  old  received  a  blow  from  a  cricket- 
bat  on  the  upper  part  of  his  forehead,  which  brought  him  to  the 
ground,  and  deprived  him  of  sense.  I  found  him  with  a  consi- 
derable tumor  on  his  forehead,  and  considering  the  state  he  was 
in,  would  have  removed  immediately  a  part  of  the  scalp;  but  a 
dabbler  in  surgery,  who  was  a  relation,  undertook  to  cure  him  by 
an  application.  On  the  third  day  I  was  sent  for  again,  and  found 
him  nearly  in  the  same  state  as  I  left  him.  I  divided  the  scalp, 
and  found  a  fracture  with  depression.  By  means  of  the  trephine 
and  elevator,  the  depressed  part  was  raised,  and  the  dura  mater 
being  found  in  a  very  good  state,  and  no  apparent  extravasation  in 
the  case,  nothing  more  was  done  at  that  time.  Proper  medicines 
were  ordered  to  procure  stools.  The  next  day  his  symptoms  were 
the  same,  except  that  his  pulse  was  less  labouring,  and  he  had  not 
the  apoplectic  stertor,  which  he  had  till  then.  I  examined  the 
bone,  which  lay  perfectly  smooth,  nor  was  the  dura  mater  at  all 
elevated  into  the  perforation.  Blood  Tvas  freely  drawn  from  the 
temporal  arteries,  and  a  stimulating  clyster  administered.  On  the 
fifth  day  no  alteration.  I  applied  a  trephine  in  the  middle  of  that 
part  of  the  bone  which  had  been  depressed  and  elevated.*^  The 
dura  mater  was  thinly  covered  with  gruraous  blood,  which  being 
gently  wiped  away,  more  of  the  same  appeared;  for  two  or  three 
days  this  discharge  continued  in  small  quantity;  the  boy  gradually 
recovered  his  senses,  and  in  due  time  got  well. 

<=  As  this  portion  of  bone  must  have  been  moveable,  or  unfirm,  the  opera- 
tion must  have  been  difficult.  Without  doubt,  so  experienced  an  operator 
as  Mr.  Pott  took  care  to  have  the  portion  of  bone  properly  supported  by  an 
assistant,  with  an  elevator.       E. 

VOL.  I.  V 


170  INJURIES    OF    THE    HEAD 


CASE  XLil. 


A  YOUNG  woman  was  thrown  out  from  a  country  waggon,  upon 
a  broad  flat  pavement,  and  was  said  to  have  pitched  upon  her 
head.  She  was  instantly  deprived  of  sense,  and  brought  to  the 
hospital  in  that  state.  Her  head  was  immediately  shaved  and 
examined,  but  found  to  be  so  absolutely  free  from  all  mark  of  vio- 
lence, that  1  was  in  doubt  of  the  truth  of  the  account  given  of  her. 
She  was  freely  let  blood,  and  some  medicines  directed  to  be  got 
down,  in  order  to  empty  her.  The  next  day  she  was  in  the  same 
state.  More  blood  was  drawn  off,  and  her  cathartic  repeated. 
The  third  day,  she  being  exactly  the  same,  both  the  temporal  ar- 
teries were  opened.  On  the  fourth,  there  being  no  alteration,  I 
determined  to  apply  a  trephine  on  that  part  of  her  head,  on  which 
she  was  said  to  have  fallen,  and  which  when  pressed  hard  seemed 
to  produce  such  motion  in  her  as  if  it  gave  some  pain.  In  a  case 
of  less  necessity  this  would  hardly  have  been  sufficient  reason: 
but  here  something  was  to  be  attempted.  I  removed  a  large  piece 
of  scalp,  and  found  the  pericranium,  though  not  detached  abso- 
lutely, yet  not  naturally  or  firmly  adherent.  I  applied  the  tre- 
phine, and  when  I  had  worked  a  few  seconds,  I  took  out  the 
instrument  to  clean  it,  but  was  much  surprised  to  find  in  it  a  piece 
of  the  upper  table  of  the  scull.  I  put  in  my  finger  to  feel  what 
was  underneath,  and  found  that  it  touched  the  remaining  table, 
which  receded  from  the  finger,  and  returned  again  upon  removing 
it;  and  when  I  pressed  the  said  loose  piece  hard,  the  girl's  whole 
frame  was  spasmodically  agitated.  What  was  to  be  done  .''  It 
appeared  to  me,  that  if  all  her  symptoms  were  not  caused  by  the 
pressure  of  the  loose  piece,  yet  they  were  certainly  aggravated  by 
it,  that  it  must  therefore  be  taken  away  at  all  events,  and  that  it 
was  much  too  large  to  be  extracted  at  the  present  opening:  beside 
\vhich,  as  it  ran  upward  toward  the  sinus,  I  should  not  have  cho- 
sen to  run  the  risk  of  an  hasmorrhage  from  thence  while  the  sinus 
was  covered  with  bone.  I  perforated  all  round  the  present  open- 
ing with  a  small  trephine,  in  such  manner,  that  each  perforation 
so  bordered  on  the  other  as  that  the  whole-  should  make  one 
opening. 


FROM   EXTERNAL   VIOLENCE.  171 

For  near  one  half  the  circle  the  outer  table  only  came  away  in 
tlie  instrument,  leaving  the  inner  loose  and  covered  with  blood, 
but  in  all  the  lower  part  the  trephine  went  through  both  tables, 
and  left  the  dura  mater  covered  with  grumous  blood  also.  When 
tlie  circle  was  finished,  the  loose  portion  was  easily  taken  away; 
its  upper  part  made  a  part  of  the  sagittal  suture,  but  no  blood  fol- 
lowed its  separation.  The  dura  mater  under  the  whole  was 
thinly  covered  with  grumous  blood.  Next  day  she  retained  her 
urine,  and  opened  her  eyes.  In  two  more  she  recovered  her 
speech,  and  became  as  rational  as  I  suppose  she  ever  had  been; 
and  would  in  all  probability  have  done  well,  as  far  as  regarded 
the  evils  produced  by  mere  pressure;  but  after  some  days  matter 
formed  between  the  detached  dura  mater  and  the  scull,  and  the 
symptomatic  fever  usually  accompanying  such  mischief  came  on 
with  such  rapidity,  that  all  the  efforts  of  art  were  vain. 


CASE  XLIII. 

A  PORTER,  at  work  at  the  water  side,  was  knocked  down  by  a 
blow  from  an  iron  hook,  at  the  end  of  the  tackle  belonging  to  a 
crane.  He  was  senseless  for  near  half  an  hour,  but  after  that  was 
so  well  as  to  walk  home.  The  next  morning  he  lost  his  sight, 
and  by  the  evening  his  speech  and  faculty  of  walking.  In  this 
state  he  was  brought  to  the  hospital.  He  was  largely  let  blood, 
and  thoroughly  emptied;  and  I  intended,  if  these  evacuations  did 
not  materially  serve  him,  to  have  examined  the  state  of  that  part 
of  the  bone  whereon  the  blow  was  received;  but  that  night  he 
died. 

Upon  examining  his  head,  a  piece  of  the  inner  table  of  the 
right  OS  parietale,  of  about  an  inch  and  half  in  length,  and  not 
quite  SO  broad,  was  found  detached  from  the  outer  table,  having 
a  quantity  of  blood  both  between  them  and  on  the  surface  of  the 
dura  mater. 

These  are  the  only  instances  which  I  have  met  with  of  fracture 
of  the  internal  table  alone;  though  I  make  no  doubt,  that  some  of 
those  who  have  been  said  and  thought  to  have  been  destroyed  by 
concussion,  have  sunk  under  this  kind  of  mischief. 


OBSERVATIONS 


THAT  DISORDER  OF  THE  CORNER  Of  THE  EYE, 


eOM:]»LOM.Y    CALLKD 


FISTULA  LACHEYMALIS. 


PREFACE. 


By  frequently  conversing  with  some  of  that  part  of  the  profes- 
sion who  come  to  London  to  attend  the  hospitals,  and  to  improve 
themselves  in  the  art  of  surgery,  it  has  appeared  to  me  that  the 
FISTULA  LACHRYMALis,  though  a  Very  common  disease,  is  one 
with  which  many  of  them  are  very  little  acquainted,  either  with 
regard  to  its  cause,  seat,  or  method  of  cure.  Some  are  totally 
ignorant  of  every  thing  relating  to  it:  others,  who  have  an  imper- 
fect idea  of  its  nature  and  seat,  are  yet  much  at  a  loss  how  to  vary 
the  method  of  treating  it,  according  to  its  different  states  and 
circumstances;  upon  which  distinction  the  probability  of  a  cure 
does  often  in  great  measure  depend;  for  if  those  means  which 
are  only  proper  in  one  state  of  the  disease  be  used  in  another,  the 
patient  will  be  fatigued  to  no  purpose;  and  the  surgeon,  by  being 
frequently  disappointed,  will  be  inclined  to  think  those  cases  in- 
curable, which  have  only  failed  through  his  own  mismanagement. 

There  is  hardly  any  chirurgical  disorder  which  requires  a  more 
close  regard  to  all  its  appearances  and  variations  than  this  does; 
and  whoever  expects  to  conduct  it  successfully,  must  attend  to  it 
constantly.  This  is,  perhaps,  the  great  reason  why  it  is  so  little 
understood;  the  object  is  too  minute,  and  the  process  often  too 
long,  to  engage  the  attention;  besides  which,  it  hardly  comes , 
under  the  name  of  an  operation,  the  great  and  almost  only  object 


176  PREFACE. 

which  they  who  come  hither  from  the  distant  countries  have  in 
view:  the  operative  part  of  surgery  is  what  they  have  seen  the 
least  of,  and  therefore  they  are  the  more  desirous  of  becoming 
acquainted  with  it:  this  desire  is  a  very  laudable  .one,  and  ought 
certainly  to  be  encouraged,  but  still  the  operative  part  of  surgery 
is  far  from  being  the  whole  of  it;  and  I  cannot  help  thinking,  that 
by  attending  a  little  more  to  what  is  called  common  or  practical 
surgery,  our  art  might  still  be  considerably  improved,  practition- 
ers rendered  more  expert,  and  mankind  much  benefited. 

The  merely  curing  diseases  is  not  all:  that  was  done  (sooner  or 
later)  while  surgery  and  anatomy  were  in  their  most  imperfect  state, 
and  while  every  branch  of  medicine  laboured  under  many  incon- 
veniences which  are  now  happily  removed;  but  the  different 
methods  in  which  chirurgical  disorders  are  treated,  or  their  cures 
attempted,  will  make  so  considerable  a  difference  in  the  confine- 
ment and  sufferings  of  the  patient,  as  to  be  very  well  worth 
attending  to. 

'  It  may  possibly  be  thought  foreign  to  my  present  purpose,  but  I 
cannot  omit  this  opportunity  of  adding  a  few  words  on  a  subject 
which  appears  to  me  highly  deserving  of  some  notice,  as  its  influ- 
ence may  be  very  extensive  and  very  prejudicial;  it  is  the  false  idea 
which  the  by-standers  at  an  operation  generally  have  of  chirurgic 
dexterity;  to  which  word  they  annex  no  other  idea  than  that  of 
quickness.  This  has  produced  a  most  absurd  custom  of  measuring 
the  motion  of  a  surgeon's  hand,  as  jockeys  do  that  of  the  feet  of  a 
horse,  viz. .by  a  stop-watch;  a  practice  which,  though  it  may  per- 
haps have  been  enrouraged  by  operators  themselves,  must  have 
been  productive  of  most,  mischievous  consequences.  Tuteetcele- 
riter  are  both  very  proper  characteristics  of  a  good  chirurgic  ope- 
ration; but  tute  stands,  as  it  should  do,  in  ihe  first  place;  as  the 
patient  who  suffers  the  smallest  'njury  from  the  hurry  of  bis  ope- 
rator, has  no  recompense  from  the  reputation  which  the  latter  ob- 


PREFACE,  177 

tains  from  the  by-standers.  In  most  of  the  capital  operations, 
unforeseen  circumstances  will  sometimes  occur,  and  must  be  at- 
tended to;  and  he  who,  without  giving  unnecessary  pain  from 
delay,  finishes  what  he  has  to  do  in  the  most  perfect  manner,  and 
the  most  likely  to  conduce  to  his  patient's  safety,  is  the  best  ope- 
rator. 

I  have  endeavoured  to  make  the  following  tract  as  plain  and  as 
intelligible  as  I  can;  and,  if  it  should  appear  prolix  to  those  who 
are  already  acquainted  with  the  subject,  I  must  beg  leave  to  ob- 
serve, that  it  was  not  written  for  their  information;  but  if  any  of 
those  who  were  unacquainted  with  it  before,  should  from  hence 
gain  any  useful  knowledge,  my  end  -will  be  answered,  and  I  shall 
be  much  gratified. 


VOL.  I. 


OF  THE 

FISTULA  LACHRYMALIS. 


SECTION  I. 

The  ancient  writers  were  in  general  so  little  acquainted  with 
the  anatomical  structure  of  the  parts  concerned  in  this  disease, 
that  both  its  cause  and  seat  have  been  very  erroneously  repre- 
sented by  most  of  them;  other  disorders,  very  different  both  from 
this  and  from  each  other,  have  been  confounded  under  the  same 
general  appellation ;  and  the  means  made  use  of  toward  obtaining 
a  cure,  being  adapted  to  such  misconceptions,  were  rough,  pain- 
ful, and  most  commonly  ineifectual. 

The  fluid  which  perpetually  moistens  the  eye,  was  supposed  to 
be  secreted  by  that  small  eminence  in  the  inner  angle,  now  called 
the  caruncule,  and  to  flow  from  thence  upward  through  the  puncta 
lachrymalia.*  The  caruncule  was  by  many  thought  to  be  the  seat 
of  the  disease  in  question,  which  was  said  to  be  produced,  either 

«  Fallopius,  who  has  very  accurately  described  the  puncta  lachrymalia,  sac- 
culus,  and  duct,  as  well  as  the  disease,  has  yet  fallen  into  this  common  error. 
"  Ad  occulos  ipsos  ex  faucibus  egrediens  yenio,  in  quibus  primum  psetermisere 
"  anatomici  duo  foramina  parvain  angulo  interna  posita,  quarum,  unum  est  in 
•'  palpebra  superiori,  alterum  in  inferiori,  in  viventibus  adhuc  hominibus,  si 
"  quis  inspicere  voluerit  apparentia,  quje  foramina  habent  meatus  qui  sub 
"  caruncula  encanthidos  vel  epicanthidos  dicta  uniuntur  in  quendam  com- 
"  munem  sinum  in  narium  cavitatera  desinentem  per  canalem  proprium  in 
"  osse  squamoso,  quod  internum  angulum  occupat  insculptum. 

"  Per  hos  meatus  major  lachrymarum  pars  ut  ego  in  fletibus  mulierum 

i'  observavi,  ad  occulos  emanat." 

TalloviV9, 


180  •  OBSERVATIONS  ON  THE 

bj  a  defliixlon  from  the  brain'' on  this  part,  or  by  an  abscess 
formed  within  the  body  of  it;  or,  by  a  lodgement  of  the  tears,  be- 
came acrid  and  corrosive  in  consequence  of  such  stagnation;*^ 
while  others  looked  upon  it  as  a  kind  of  encysted  tumor.  The 
swelling  in  the  inner  corner  of  the  eye,  the  frequently -attendant 
ophthalmy,  t{ie  involuntary  flux  of  serum  down  the  cheek,  the  ex- 
coriation of  the  eye-lid,  and  the  discoloured  discharge  upon  pres- 
sure, strengthened  their  opinions,  and  confirmed  their  prejudices. 
They  who  supposed  it  to  be  caused  originally  by  a  defluxion 
of  the  inflammatory  kind,  tending  to  produce  an  abscess,  had 
recourse  at  first  to  those  general  -  ethods  and  means  which  were 
thought  most  likely  to  prevent  such  consequence:  these  not  an- 
swering, they  proceeded  to  open  the  supposed  abscess,  and  to 
endeavour  the  digestion  of  it:  on  the  other  hand,  they  who  sup- 
posed it  to  be  an  encysted  tumor  attempted  the  eradication  of  it 

*•  Non  enim  os  solummodo  cariosum,  verum  etiam  glan;lula  ita  erosa  erat, 
"  ut  quotiescunque  puer  ploraret,  lachrymae  per  ipsam  fistulam  copiose  ex- 
"  tillarent." 

HlLDANUS. 

'■  "  Fistula  lachrymalis  sit  ex  humorum  decursu,  qui  currunt  ad  lachvymalis 

"  angulum  juxta  nasam,  nee  propter  eorum   multitudinem,  et  grossitatem 

"  possunt  exire,  &.c.  hi  autem  morantes  ibi  diutius  corrurapuntur,  et  locum 

"  ulcerant." 

Lakfranc. 

"  JEgylops  est  tumor  abscessorius  inter  majorem  angulum,  et  nares  pro- 
"veniens." 

Pauius. 

*■■  "At  the  gi'eat  corner  of  the  eye  there  is  a  glandule  made  for  receiving 
"  and  containing  the  moisture  which  serves  for  lubricating  the  eye ;  this 
"  glandule  sometimes,  by  a  sanguine  or  pituitous  defluxion  falling  violently 
"  from  the  brain,  swells  and  impostumates,  and  ulcerates,"  &c. 

Amb.  Parey. 

"  Hsec  caruncula  ab  acrium  humorum  affluxu  turget,  nonnunquam  intu- 
"  mescit,  et  abscedit  ulceraturque,  ulcere. non  raro  in  fistulam  abeunte,  adeo 
"ut  subjectum  os  corrumpatur." 

MuNJflCKS. 

•'Per  pusillum  utriusque  palpebrse   foramen  lachrymals  naturaliter  ef- 

"  fluunt." 

Fab.  ab.  AdtrAPENDEUTE. 

"Lachrymx  veniunt  per  lachrymalia  a  foramine  quodam  parvo,  et  quasi 
*'  insensibili  in  fine  pilorum." 

GUIDO. 


FISTULA   LACHRYMALIS.  181 

either  by  knife,  caustic,  or  cautery;  and  all  of  them  taking  it  for 
granted,  when  the  discbarge  was  apparently  purulent,  or  much 
discoloured,  that  the  bone  was  rotten,  advise  the  use  of  escharotic 
applications,  or  the  hot  iron,  to  destroy  the  callosity,  and  to  dry 
and  exfoliate  the  caries;  and  these  methods  failing,  as  in  the 
nature  of  things  they  very  frequently  must,  they  pronounced  the 
disease  to  be  incurable. 

A  more  minute  and  careful  examination  into  the  anatomy  of  the 
parts  has  given  us  a  more  true  idea  of  the  disorder,  and  furnished 
us  with  a  more  rational,  as  well  as  a  more  successful,  method  of 
treating  it.  We  now  know  that  the  caruncule  is  not  the  organ 
which  secretes  the  tears,  but  that  this  office  is  performed  by  a 
gland,  situated  near  the  outer  corner  of  the  eye;  that  the  lach- 
rymal fluid  is  in  its  nature  perfectly  innoxious;  that  an  obstruc- 
tion in  the  nasal  duct  is  most  frequently  the  primary  and  original 
cause  of  the  complaint;  and  that  its  seat  is  in  the  sacculus 
lachryraalis. 

Upon  these  principles  the  modern  practitioners  have,  with 
great  industry  and  ingenuity,  endeavoured  to  find  out  some  means 
whereby  this  obstruction  may  be  removed,  and  the  parts  restored 
to  their  natural  and  healthy  state,  without  such  pain,  destruction, 
and  deformity,  as  the  ancient  methods  occasioned;  or,  these  fail- 
ing, to  establish  a  new  artificial  passage, .  which  may  in  some 
measure  supply  the  place  of  the  natural  one. 

All  these  means  have  the  merit  of  being  founded  on  the 
natural  structure  of  the  parts  concerned.  When  the  more 
easy  and  mild  ones  succeed,  the  patient  gains  a  considerable 
advantage;  and  when  they  do  not,  little  time  is  lost,  nor  is  any 
more  efficacious  method  rendered  thereby  less  practicable:  in 
this,  as  in  every  other  part  of  surgery,  the  more  simple  means 
ought  to  be  first  tried;  pain  should  be  avoided  as  much  as  possi- 
ble, except  when  absolutely  necessary,  and  then  it  must  be  sub- 
mitted to. 


182  OBSERVATIONS    ON   THE 


SECT.  II. 


That  the  motions  of  the  eye-lids  may  be  performed  with  the 
utmost  ease,  that  the  tunica  cornea  may  be  kept  constantly  clean, 
bright,  and  fit  for  the  transmission  of  the  rays  of  light,  and  that 
dust,  and  other  hurtful  particles,  may  be  immediately  washed 
away,  the  surface  of  the  eye  is  continually  moistened  by  a  fine 
limpid  fluid. 

This  fluid  is  derived  principally  from  a  large  gland,  situated 
under  the  upper  edge  of  the  orbit  near  the  outer  corner  of  the 
eye,  which  gland  is  of  the  conglomerate  kind,  and  lies  in  a  small 
depression  of  the  os  fi-ontis;  its  excretory  ducts,  or  those  by  which 
it  discharges  the  secreted  fluid,  piercing  the  tunica  conjunctiva, 
just  above  the  cartilaginous  borders  of  the  upper  eye-lids. 

While  the  caruncule  was  thought  to  be  the  secretory  organ  of 
the  tears,  this  gland  bore  the  title  of  glandula  innominata;  but 
now  that  its  use  and  office  are  known,  it  is  called  glandula  lachry- 
malis. 

By  irritation  from  any  sharp  or  poignant  particles,  a  large 
quantity  of  this  fluid  is  immediately  secreted,  and  by  the  motion 
of  the  eye-lids  is  as  immediately  derived  over  the  surface  of  the 
eye,  by  which  means  such  particles  are  waslied  and  wiped  off". 
Sometimes  also  the  passions  of  the  mind  produce  an  immediate 
increase  of  this  lymph,  which  is  then  strictly  and  properly  called 
tears;  a  constant  secretion  of  too  large  a  quantity  causes  a  disease, 
called  epiphora;  and  a  deficiency  of  it  makes  the  motions  of  the 
lid  difficult  and  painful. 

Although  the  fluid  secreted  by  the  lachrymal  gland  is  consider- 
able in  quantity,  yet  when  it  is  not  suddenly  produced  by  irrita- 
tion from  without,  or  passion  within,  it  is  so  constantly  and  gradu- 
ally carried  off",  as  to  create  neither  trouble,  uneasiness,  nor 
blemish. 

The  edge,  or  border  of  each  eye-lid,  is  formed  by  a  thin  carti- 
lage, the  figure  and  consistence  of  which  keep  the  lids  properly 
expanded;  these  cartilages  are  covered  by  a  fine  membrane,  and 
are  called  cilia;  their  internal  edges  do,   upon  every  motion. 


FISTULA  LACHRYMALIS.  183 

sweep  over  every  point  of  the  surface  of  the  cornea;  this  motion, 
though  almost  imperceptible  unless  attended  to,  is  very  frequently 
performed;  and  as  the  secretion  of  the  fluid  is  also  constant,  the 
eye  is  by  this  means  kept  always  moist,  clean,  and  bright. 

At  the  extremity  of  each  of  these  cartilaginous  borders  of  the 
eye-lids,  on  the  side  next  the  nose,  is  the  small  papilla,  or  emi- 
nence; and  in  the  middle  of  each  of  these  is  a  small  hole,  or 
perforation,  which  being  made  in  the  cartilage  is  not  liable  to 
collapse  while  the  parts  are  in  a  sound  state,  but  remains  always 
open;  they  are  called  the  puncta  lachrymalia,  and  their  office  is 
to  receive  the  lachrymal  fluid,  as  it  runs  off"  the  corner  along  the 
edges  of  the  eye-lids,  thereby  preventing  it  from  trickling  down 
the  cheek;  and  that  there  may  be  no  impediment  to  the  constant 
execution  of  this  office,  during  the  time  of  sleep,  as  well  as  that  of 
being  awake,  the  internal  edges  of  the  cilia  do  not  come  into 
immediate  contact  with  each  other  in  that  point  where  these 
orifices  are. 

From  each  of  these  puncta  lachrymalia  proceeds  a  small  mem- 
branous tube,  which  tubes  soon  enter  into,  or  form  a  pouch  or  bag, 
situated  near  the  inner  angle  of  the  eye,  just  below  the  union  of 
the  two  lids,  under  the  musculous  orbicularis  palpebrarum;  the 
bag  is  called  the  sacculus  lachrymalis,  and  its  office  is  to  receive 
all  the  lymph  brought  by  the  puncta  and  ducts:  the  upper  part  of 
this  sacculus  lies  in  an  excavation,  formed  partly  by  the  nasal 
process  of  the  os  maxillare  superius,  and  partly  by  the  os  unguis; 
the  lower  part  of  it  is  confined  in  a  long  channel,  and  forms  a 
tube,  or  duct,  which  descending  obliquely  backward  communi- 
cates with  the  cavity  of  the  nose,  behind  the  os  spongiosum  supe*^ 
rius,  by  an  opening  whose  size  is  somewhat  different  in  different 
subjects. 

This  passage  is  called  the  ductus  ad  nares  or  the  ductus  nasalis, 
and  through  it  whatever  is  received  by  the  sacculus  from  the 
puncta,  does,  in  a  healthy  and  sound  state  of  these  parts,  pass  into 
the  nose. 

The  membrane  which  lines  this  sacculus  and  duct,  is  in  its 
structure  much  like  to  the  membrana  pituitaria  narium,  from  the 
surface  of  which  a  clear  viscid  mucus  is  secreted,  and  by  which 


184  OBSERVATIONS  ON  THE 

the  sacculus  and  passages  are  constantly  moistened  and  kept  per- 
vious. 

While  the  parts  are  in  a  healthy  sound  state,  the  fluid  se-  - 
creted  by  the  lachrymal  gland  passes  off  through  the  puncta,  sac- 
sulus,  and  duct,  into  the  nose,  without  any  trouble;  but  when  they 
are  in  a  diseased  state  the  case  is  otherwise.  This  membrane, 
like  all  other  vascular  parts,  is  liable  to  inflammation,  by  which 
means  it  often  happens  that  it  is  so  thickened  as  to  obstruct  the 
nasal  duct,  and  thereby  much  impede,  or  totally  hinder,  the  pass- 
age of  any  thing  through  it;  in  consequence  of  which  obstruction 
the  sacculus  is  filled  by  its  natural  mucus,  and  the  derivation  of 
the  serum  from  the  lachrymal  gland  through  it  being  thus  pre- 
vented, it  runs  off  from  the  eyelids  down  the  cheek:  this  obstruc- 
tion continuing,  and  the  mucus  still  lodging,  the  sacculus  is  dilat- 
ed, and  produces  that  tumor  in  the  inner  corner  of  the  eye,  and 
that  discharge,  upon  pressure,  which  characterise  the  first  state  of 
the  disease  in  question,  and,  in  conjunction  with  several  other 
attending  symptonis,  prove  its  seat  to  be  in  the  lachrymal  sac, 
and  nasal  duct. 


SECT.  III. 

Although  the  seat  of  this  disease  is  the  same  in  almost  every 
subject,  yet  its  appearance  is  very  diflerent  in  different  persons, 
and  under  different  circumstances.  These  variations  depend 
principally  on 

1.  The  degree  of  obstruction  in  the  nasal  duct. 

2.  The  state  of  the  cellular  membrane  covering  the  sac. 

3.  The  state  of  the  sacculus  itself. 

4.  That  of  the  bone  underneath. 

5.  The  general  state  and  habit  of  the  patient.^ 

^  As  the  state  and  circumstances  of  this  disease  are  really  various,  and  dif- 
fer very  essentially  from  each  other,  the  general  custom  of  calling'  them  all 
by  the  one  same  of  fistula  lachrymalis  is  absurd. 


'  FISTULA  LACHRYMALI3.  185 

Sometimes  a  serous  kind  of  d^fluxion,  by  which  the  lining  of 
the  sac  and  duct  is  so  thickened  as  to  obstruct,  or  prevent,  the 
passage  of  the  fluid  through  them  into  the  tiose,  makes  the  whole 
complaint;  and  the  cellular  membrane  on  the  outside  not  being  dis- 
eased, there  is  no  appearance  of  inflammation.  In  this  case  the 
duct  is  stopped,  and  the  sacculus  dilated,  but  without  any  altera- 
tion in  the  colour  of  the  skin;  a  fulness  appears  in  the  corner  of 
the  eye  next  to  the  nose;  and  upon  the  application  of  a  finger  to 
this  tumor,  a  clear  viscid  mucus  is  discharged  through  the  puncta 
lachrymalia:  the  patient  feels  no  pain,  nor  finds  any  inconve- 
nience, except  what  is  produced  by  the  discharge  of  this  mucus, 
and  by  the  trickling  of  the  lymph  down  (he  cheek. 

In  some  cases  the  mucus  is  not  perfectly  and  always  clear,  but 
it  is  sometimes  cloudy,  and  looks  as  if  it  had  a  mixture  of  milk  or 
cream  in  it:  at  first  waking,  some  of  it  is  generally  found  in  the 
corner  of  the  eye;  and  the  eye-lashes,  being  smeared  over  with  it 
during  sleep,  most  commonly  adhere  together  in  the  morning. 

This  is  the  most  simple  state  of  the  disease,  what  the  French 
have  called  the  hernia,  or  hydrops  sacculi  lachrymalis:  it  is  fre- 
quently met  with  in  children  who  have  been  rickety,  or  are  sub- 
ject to  glandular  obstructions;  and  in  this  sfate  it  sometimes  re- 
mains for  some  years,  subject  to  little  alterations,  as  the  health  or 
habit  shall  happen  to  vary,  the  sacculus  being  sometimes  more, 
sometimes  less  full,  and  troublesome;  the  mucus  which  is  pressed 
out  is  sometimes  more,  sometimes  less  cloudy,  and  now  and  then 
it  is  attended  with  a  slight  ophthalmy,  or  an  inflammation  of  the 
eye-lids,  but  which  by  common  care  is  easily  removed. 

When  the  sacculus  is  not  much  dilated,  the  discharge  small, 
and  produced  only  by  pressure,  the  chief  inconveniences  are  the 
weeping  eye,  and  the  gumming  together  of  the  lids,  after  sleeping: 
but  these,  by  being  attended  to,  may  be  kept  from  being  very 
troublesome;  and  if  the  disease  makes  no  farther  progress,  may 
be  so  regulated  as  to  render  any  more  painful  process  totally  un- 
necessary. 

When  the  dilatation  is  considerable,  the  swelling  is  more  visible, 
and  the  quant  ty  of  mucus  is  larger:  it  is  also  in  this  state  more 
frequently  mixt  and  cloudy,  and  more  troublesome,  from  the  more 
frequent  necessity  of  emptying  the  bag.     But  if  the  patient  be 

VOL  I.  A  a 


186  OBSERVATIONS  ON  THE 

adult,  it  may,  even  in  this  more  dilated  state  of  it,  be  kept  from 
being  very  inconvenient. 

If  an  inflammation  comes  on,  the  tumor  is  thereby  considera- 
bly increased,  the  discharge  is  larger,  as  well  during  sleep  as  upon 
pressure;  the  skin  covering  it  loses  its  natural  whiteness  and  soft- 
ness, becomes  hard,  and  acquires  an  inflamed  redness;  and  with 
the  mucus  a  mixture  of  something,  which  in  colour  resembles 
matter,  is  discharged,  especially  if  the  pressure  be  made  with  any 
force,  or  continued  for  any  time:  this  circumstance,  added  to  the 
painful  sensation,  and  inflamed  appearance  of  the  parts,  has  been 
productive  of  a  supposition,  that  in  this  there  is  either  an  ulcer 
or  an  abscess  within  the  sacculus  or  duct. 

As  this  is  an  opinion  which,  though  it  may  possibly  sometimes 
have  some  foundation  in  truth,  yet  it  is  in  general  entertained 
much  too  hastily,  and  is  also  the  principal  source  whence  most  of 
the  mistakes  concerning  this  disease  have  sprung,  I  would  beg 
leave  to  be  indulged  a  few  words  on  this  subject. 

It  has  already  been  observed,  that  from  the  surface  of  the  mem* 
brane  which  lines  these  parts  a  thin  mucus  is  secreted,  by  which 
its  surface  is  smeared  over,  in  the  same  manner  as  is  that  of  all 
the  membrane  which  covers  or  lines  the  fauces,  larynx,  and  in- 
ternal parts  of  the  nose,  the  antra  of  the  jaws,  and  the  sinuses  of 
the  sphenoid  and  ethmoid  bones,  &c.  While  the  lachrymal  sac 
is  free  from  disease,  and  the  ductus  ad  nares  open,  this  mucus  is 
nearly  limpid  in  colour,  small  in  quantity,  and  passes  insensibly 
into  the  nose  with  the  fluid  from  the  lachrymal  gland;  but  when, 
by  the  obstruction  of  the  nasal  duct,  that  passage  is  denied,  it  ne- 
cessarily lodges  in  the  sacculus;  by  distending  and  irritating  its 
containing  bag  it  is  increased  in  quantity,  altered  in  colour,  and 
discharged  at  the  puncta  lachrymalia,  as  it  either  becomes  too 
much  for  the  sac  to  contain,  or  as  it  is  forced  out  by  pressure. 
This  is  a  short  and  succinct  account  of  the  true  nature  of  the  dis- 
ease, and  such  as  will  fairly  and  truly  account  for  all  its  symp- 
toms and  appearances,  without  any  recourse  to  either  abscess  or 
ulcer,  circumstances  which  very  seldom,  if  ever,  attend  it. 

That  which  is  mixed  with  the  clearer  part  of  the  mucus,  and 
which  from  its  pale  yellow  hue  is  taken  for  matter,  is  not  matter, 
but  mucus,  which  in  this  part,  as  well  as  several  others  in  the 


FISTULA  LACHRYMALIS.  187 

body,  does,  either  by  being  confined  beyoml  the  necessary  time, 
or  by  inflammation,  or  irritation  of  the  gland  or  membrane  which 
secretes  or  contains  it,  or  even  from  general  affection  of  the  habit, 
put  on  a  yellow  purulent  colour,  where  there  is  neither  abscess 
nor  ulcer  in  the  part  whence  it  comes. 

So  many  instances  of  this  are  producible  as  to  put  the  matter 
beyond  all  doubt;  the  urethra,  vagina,  and  all  the  sinuses  of  the 
head  which  communicate  with  the  nose,  furnish  us  with  them 
daily;  the  linings  of  all  these  are  constantly  imbued  with  a  mu- 
cus naturally  clear,  and  no  more  in  quantity  than  is  necessary  to 
keep  the  membranes  moist;  but  either  inflammation  or  irritation 
does  immediately  so  add  to  its  quantity,  and  so  alter  its  colour, 
that  in  the  two  former  the  same  mistake  has  often  been  made  as 
in  the  subject  in  question;  that  is,  the  discharge  has  been  thought 
to  be  purulent,  and  produced  by  ulceration  of  the  parts. 

These  two  fluids,  pus  and  mucus,  which  have  been  so  frequent- 
ly confounded  together,  do  really  differ  so  widely  from  each  other 
in  their  nature,  constitution,  sources,  purposes,  and  effects,  that  to 
distinguish  them  properly,  and  to  point  out  the  true  character  of 
each,  seems  to  be  a  matter  of  much  importance:  it  would  carry 
me  too  wide  from  my  present  purpose  to  attempt  it  in  this  place, 
and  therefore  I  shall  only  just  mention  what  may  serve  merely  to 
illustrate  that. 

If  I  conceive  rightly  of  this  affair,  mucus,  considered  in  a  gene- 
ral sense,  is  the  jfffect  of  a  natural  secretion  made  by  glands, 
membranes,  or  other  bodies  appointed  for  that  purpose,  and  is  so 
far  from  being  originally  the  consequence  of  disease,  that,  in  a 
due  quantity,  it  is  absolutely  necessary  for  several  very  important 
purposes  in  the  animal  economy;  which  purposes,  when  this  fluid 
is  deficient,  must  be  ill  executed,  and  some  kind  of  disease  or  de- 
fect follow:  whoever  will  reflect  upon  the  uses  of  it  in  the  intes- 
tines, joints,  sheaths,  or  capsulae  of  the  tendons,  in  the  sinuses  of 
the  sculi  serving  the  purposes  of  speech,  in  the  cavity  of  the  nose, 
where  the  olfactory  nerves  do  their  duty,  in  the  prostate  gland, 
larynx,  trachea,  urethra,  and  vagina,  will  be  easily  convinced  of 
the  truth  of  this  assertion,  both  with  regard  to  its  natural  uses  in 
a  healthy  state  and  proper  quantity,  and  the  share  it  frequently 


188  OBSERVATIONS  ON  THE 

has  in  the  production  of  diseases,  when  it  is  either  vitiated  or  re- 
dundant. 
'  Pus,  or  matti-r,  is  certainly  no  natural  secretion;  suppuration, 
though  it  be  an  act  of  nature  when  some  paris  of  the  body  have 
been  forcibly  divided  from  each  other,  is  nevertheless  to  be  re- 
garded as  the  effect  of  violence  and  destruction,  at  least  of  divi- 
sion; for,  without  entering  minutely  into  the  origin  or  nature  of  it, 
I  believe  I  may  venture  to  affirm,  that  the  dissolution  of  some  of 
the  solid  particles  of  broken  capillary  vessels,  and  a  mixture  of 
some  part  of  the  juices  which  should  circulate  through  them, 
make  a  necessary  part  of  its  production.  However  constant  its 
appearance  may  be  in  the  progress  toward  healing  a  wound  or 
sore,  yet  it  never  is  produced,  even  in  the  smallest  quantity,  with- 
out some  degree  of  erosion,  some  breach  in  the  natural  structure 
of  the  parts;  and  when  such  breach  is  healed,  the  discharge  ne- 
cessarily ceases. 

On  the  contrary,  mucus  may,  by  irritation,  relaxation,  or  de- 
fluxion,  on  its  secreting  or  containing  parts  or  organs,  be  increas- 
ed to  a  quantity  far  beyond  what  is  necessary  or  useful,  and  pro- 
duce thereby  a  disease  in  parts  where  there  is  not  the  least 
degree  of  solution  of  continuity,  as  in  the  cases  of  tenesmus,  stone 
in  the  bladder,  fluor  albus,  and  simple  gleets  from  the  urethra;  as 
also  in  that  kind  of  deOuxion  on  the  nose  and  fauces,  producing  a 
catarrh,  and  in  the  immediate  effect  of  all  sternutatories. 

Other  differences  between  the  nature  and  pi^perties  of  the  two 
fluids  might  be  mentioned;  but  if  these  already  cited  are  just,  they 
will  be  sufficient  to  evince  the  impropriety  of  confounding  them 
together,  either  with  regard  to  theory  or  practice. 

Nor  is  this  mistake  of  discoloured  mucus  for  matter  confined  to 
the  lachrymal  sac  only;  the  two  circumstances  of  pain,  and  yellow 
colour,  having  in  almost  all  times  produced  the  same  misconcep- 
tion in  the  virulent  gonorrhoea  of  both  sexes  :  this  has  been  called 
pus,  and  being  said  to  proceed  from  ulcerations  in  the  urethra  and 
vagina,  though  the  repeated-  testimony  of  those  who  have,  imme- 
diately after  death,  examined  the  parts  of  persons  so  diseased,  has 
often  been  produced  to  the  contrary,  and  though  the  discharge  itself 
•when  properly  examined  will  always  prove  the  contrary,  inflam- 
mation and  irritation  of  the  membranous  linings  of  the  urethra 


FISTULA  LACHRYMALIS.  189 

and  vagina  will  fully  account  for  all  the  appearances  in  this  disease, 
in  which  there  is  neither  matter,  nor  ulcer,  nor  abscess:  whoever 
will  attend  to  the  discharge  made  from  a  purulent  ulcer,  will  find 
it  widely  different  from  that  which  issues  from  either  of  the  above 
parts  in  the  gonorrhoea. 

Again,  in  case  of  strictures  in  the  male  urethra,  the  discharge 
occasioned  by  a  bougie,  properly  and  judiciously  used,  is  a  disco- 
loured mucus,  and  not  matter,  though  it  is  generally  so  called:  it 
is*  from  the  discharge  of  this  mucus,  and  the  dilatation  of  the  pass- 
age, that  the  relief  is  obtained,  not  from  any  destruction  or  divi- 
sion of  parts:  the  bougie  which  produces  true  matter  does  much 
mope  harm  than  good,  and  makes  a  sore  where  there  was  none, 
and  where  there  ought  to  be  none.  How  often  do  catarrhous  de- 
fluxions  on  the  trachea  and  larynx  wear  toward  the  close  a  deep 
purulent  colour,  so  as  to  deceive  the  unknowing  into  an  opinion, 
that  it  is  matter  upon  the  lungs?  But  no  judge  of  these  things  ever 
had  recourse  to  abscesses,  or  ulcers  for  a  solution  of  such  appear- 
ance. The  argument  drawn  from  the  quantity  of  these  discharges 
is  as  erroneous  as  those  taken  from  its  colour;  as  an  inflammatory 
defluxion  on  the  part  does  generally  occasion  the  latter,  so  mere 
irritation  will  produce  the  former,  which  does  also  generally  cease 
when  the  irritating  cause  is  removed  or  appeased.  How  imme- 
diately is  a  most  troublesome  totnesmus  cured  by  a  clyster  of  starch 
and  opium .f*  What  large  foetid  discharges  are  made  from  behind 
the  prepuce  of  many  persons,  not  only  free  from  all  venereal  taint, 
but  without  any  ulceration  of  the  parts,  by  a  kind  of  exsudation? 
To  what  length  of  time  will  they  not  continue,  if  neglected,  and 
how  immediately  do  they  cease  by  the  use  of  a  spirituous  or 
vitriolic  wash?  How  often  is  the  fiuor  albus,  even  in  some  of  its 
worst  circumstances,  moderated,  not  to  say  cured,  merely  by  wash- 
ing away  the  acrid  mucus,  which,  lodging  in  the  rug®  of  the 
vagina,  continually  irritated  the  parts  to  a  fresh  discharge,  and 
perpetuated  the  disease?  What  quantity  of  slime  is  there  in  the 
urine.of  those  who  have  a  stone  in  the  bladder?  And  how  totally 
does  it  cease,  upon  that  stone  being  discharged,  or  iaken  away? 
Whereas  neither  cleansing  of  parts,  nor  removal  of  irritating 
bodies,  does,  or  ever  can  procure,  an  immediate  cessalioa  of  a  dis- 
charge of  true  matter,  which  being  occasioned  by  a  solution  of  con- 


190  OBSERVATIONS  ON  THE 

tinuity,  an  erosion  or  division  of  the  parts  whence  it  proceeds 
must  decrease  gradually,  and  at  last  can  only  cease  by  such  part 
becoming  whole  again. 

In  short,  the  two  fluids  are  so  absolutely  diflerent  and  distinct, 
that  the  blending  them  together  in  our  ideas  of  disease,  proceed- 
ing from,  or  producing  either  of  ihem,  cannot  be  too  industriously 
avoided.  It  is  a  subject  on  which  a  great  deal  more  might  be 
said,  as  it  would  comprehend,  or  have  relation  to  many  disorders 
which  perhaps  are  not  sufficiently  understood,  or  attended  to;  but 
being  beside  my  present  purpose,  I  shall  say  no  more  about  it,  only 
desire  that  I  may  not  be  misunderstood  as  if  I  meant  to  assert, 
that  there  never  is  abscess  or  ulcer  in  the  lachrymal  sac  and  duct: 
No,  I  only  mean  to  signify,  that  it  is  my  opinion,  that  the  yellow 
or  purulent  colour  of  the  discharge,  which  is  generally  received  as 
a  proof  of  such,  is  no  proof  at  all;  that  this  colour  may  be,  and 
most  frequently  is,  dependent  on  other  causes;  that  though  by  the 
suppuration  of  the  cellular  membrane  covering  the  sac,  the  upper 
part  of  it  sometimes  becomes  sloughy,  and  bursts;  yet  the  lower 
part  of  it,  and  the  nasal  duct,  are  often  at  the  same  time  perfectly 
sound;  and  that  there  never  is  abscess  or  ulcer  within,  while  the 
skin  is  entire,  and  preserves  its  natural  hue  and  softness,  let  the 
colour  of  the  discharge  be  ever  so  yellow;  circumstances  of  no 
small  consequence  in  the  treatment  of  this  disease,, 

The  inflammation  of  the  cellular  membrane  covering  the  sac, 
is  a  circumstance  which  makes  a  considerable  diflerence,  both  in 
the  appearance  of  the  disease,  and  in  its  requisite  treatment:  in 
some  cases  it  is  confined  merely  to  the  surface  of  the  tumor  in  the 
corner  of  the  eye;  in  others,  it  spreads  still  farther,  affecting  the 
eye-lids,  cheek,  and  side  of  the  nose. 

When  the  parts  are  in  this  state,  the  mucus  within  the  bag  has 
generally  the  appearance  of  being  matter,  that  is,  it  wears  a  deep 
yellow  colour,  and  is  of  a  more  thin  consistence.  If  the  puncta 
lachrymalia  are  naturally  large  and  open,  and  the  inflammation 
confined  to  the  surface  of  the  sac,  its  contents  will  pass  off  pretty 
freely,  and  the  skin  will  remain  entire:' this  is  what  the  ancients 
called  the  simple,  or  imperfect,  or  anchylops. 

But  when  the  skin  covering  the  lachrymal  bag  has  been  for 
some  time  inflamedj  or  subject  to  frequently  returning  infiamma- 


FISTULA  LACHRYMALIS.  191 

tions,  it  most  commonly  happens,  that  the  puncta  lachrymalia  are 
affected  by  it,  and  the  fluid,  not  having  an  opportunity  of  passing 
off  through  them,  distends  the  inflamed  skin,  so  that  at  last  it  be- 
comes sloughy,  and  bursts  externally.  This  is  that  state  of  the 
disease  which  is  called  perfect  Aigylops,  or  iEgylops;  the  dis- 
charge which  used  to  be  made  through  the  puncta  lachrymalia, 
while  the  skin  was  entire,  is  now  made  through  the  new  opening, 
and,  by  excoriating  the  eye-lids  and  cheek,  increases  the  inflam- 
mation, and  gives  the  disease  a  much  more  disagreeable  appear- 
ance. In  some  the  matter  bursts  through  a  small  hole,  and,  after 
it  has  discharged  itself,  the  tumor  subsides,  the  neighbouring  parts 
become  cool,  and,  though  the  skin  covering  the  surface  of  the  sac- 
culus  is  sloughy  and  foul,  yet  there  is  no  reason  to  believe  that  the 
sac  itself  is  much  diseased  below;  in  others  the  breach  is  large,  the 
skin  remains  hard  and  inflamed,  and,  from  the  appearance  of  the 
sore,  there  is  reason  to  suppose  the  whole  inside  of  the  bag  to  be  in 
a  diseased  state;  and,  in  some  cases,  which  have  been  much  ne- 
glected or  irritated  by  ill  treatment,  the  cavity  of  the  sacculus 
seems  to  be  filled  with  a  loose  ill-natured  fungus,  which  gleets 
largely,  and  produces  inflammation  and  excoriation  of  all  the  parts 
about. 

There  is  also  another  circumstance  which  sometimes  is  found 
to  attend  this  disorder,  viz.  a  carious  state  of  the  bones.  This  was 
by  our  forefathers  supposed  to  be  a  frequent  one,  and  was  the  prin- 
cipal reason  for  their  so  free  use  of  caustic,  cautery,  and  scalpra, 
in  the  treatment  of  it;  but,  since  the  disease  has  been  more  mi- 
nutely examined  into,  this  <;ircumstance  has  been  found  to  be  a 
very  rare  one.  When  the  fistula  lachrymalis  is  a  symptom  of  the 
lues  venerea,  as  it  sometimes  is,  the  bones  are  indeed  often  carious; 
but  then,  the  fistula  is  not  the  original  complaint,  but  produced 
secondarily,  and  is  a  consequence  of  the  diseased  state  of  the  os 
ethmoides,  and  ossa  spongiosa,  of  the  nose,  and  is  not  curable  by 
any  local  means  or  applications,  but  depends  entirely  on  the  cure 
of  the  disease  of  which  it  is  a  symptom. 

I  have  also  seen  an  abscess  after  the  small-pox,  which,  by  falling 
on  the  lachrymal  bag,  has  made  it  all  slough  away,  and  leave  the 
bones  bare;  which  circumstance  I  have  also  seen  attend  the  free 
use  of  stroiig  escharotics  applied  to  destroy  what  is  called  the  cyst: 


192  OBSERVATIONS  ON  THE 

but,  without  the  accession  of  some  other  disorder  producing  it,  or 
the  most  absurd  method  of  treating  the  complaint,  I  believe  that  a 
caries  of  the  bones  will  very  seldom  be  met  with.  Indeed  the 
combination  of  other  diseases,  either  of  the  general  habit,  or  af- 
fecting the  same,  or  the  neighbouring  parts,  does  often  make  a  very 
material  difference,  both  in  the  appearance  of  the  disorder,  in  the 
prognostic,  and  in  the  proper  method  of  treating  it,  which,  there- 
fore, should  always  be  inquired  into:  for  instance,  the  patient  is 
sometimes  subject  to  an  habitual  opbthalmy,  or  lippitudo,,  which 
will  add  to  the  deformity,  and  give  a  good  deal  of  adiliiional  trou- 
ble during  the  cure;  an  ozajna,  or  some  other  disease  of  the  mem- 
brane, and  cells  of  the  ethmoid  bone,  or  a  polypose  excrescence 
within  the  nose,  are  now  and  then  combined  with  it:  the  habit  is 
sometimes,  as  I  have  before  observed,  infected  with  the  lues  ve- 
nerea, of  which  this  disease  may  be  a  symptom;  stiumous  glandu- 
lar obstructions  are  its  too  frequent  companions;  and,  what  is  worst 
of  all,  it  is  sometimes  cancerous. 


SECT.  I. 


From  what  has  been  said,  I  think  it  will  appear  that  this  dis- 
ease, in  its  primary  and  most  simple  state,  consists  in  a  detentioa 
or  lodgement  of  mucus  in  the  sacculus  lachrymalis,  in  consequence 
of  an  obstruction  of  the  natural  passage  from  that  bag  into  the  nose; 
that  by  means  of  this  lodgement  the  sacculus  is  distended,  irritated, 
and  sometimes  inflamed;  that  the  fluid  which  passes  from  the  la- 
chrymal gland  over  the  eye  to  the  puncta  lachrymaiia,  being  pre- 
vented by  the  fulness  of  the  sac  from  getting  into  it,  runs  down  the 
cheek;  and  therefore  that  the  characteristic  marks  of  the  disorder^ 
when  recent,  are  a  small  tumor  in  the  corner  of  the  eye,  an  invo- 
luntary flux  of  serum  down  that  side  of  the  face,  and  a  discharge 
of  mucus  through  the  puncta  lachrymaiia  upon  pressure. 

This  lodgement,  being  originally  produced  by  the  stoppage  of 


FISTULA   LACHRYMALIS.  19S 

the  natural  duct,  it  follows,  that  the  first  curative  intention  is,  the 
removal  of  that  obstruction;  which  is  sometimes  practicable,  but 
more  often  not;  the  degree  of  obstruction,  its  dale,  the  state  of 
the  adjacent  parts,  and  some  other  circumstances,  rendering  it  more 
or  less  so  in  different  subjects. 

That  the  inexperienced  practitioner  may  be  guarded  against 
giving  a  hasty  prognostic,  or  making  attempts,  which,  however 
fatiguing  to  the  patient,  must  in  the  end  prove  fruitless;  and  that 
he  may  be  enabled  to  understand  the  disease  more  perfectly,  I 
shall  take  the  liberty  to  divide  it  into  four  general  heads,  or  states, 
under  which  all  its  lesser  distinctions  may  be  comprehended. 

The  first  consists  in  a  simple  dilatation  of  the  saccuius,  and 
obstruction  of  the  nasal  duct,  discharging  upon  pressure  a  mucus 
either  quite  clear  or  a  little  cloudy;  the  skin  covering  the  bag 
being  entire  and  perfectly  free  from  inflammation. 

In  the  second,  the  tumor  is  somewhat  larger;  the  skin  which 
covers  it  is  in  an  inflamed  state,  but  entire;  and  the  discharge 
made  through  the  puncta  lachrymalia  is  of  a  pale  yellow,  or  puru- 
lent colour. 

In  the  third,  the  skin  covering  the  saccuius  is  become  sloughy 
and  burst,  by  which  means  the  swelling  is  in  some  measure  less- 
ened; but  the  mucus,  which,  while  the  skin  was  entire,  used  to 
be  pressed  out  through  the  puncta  lachrymalia,  now  discharges 
itself  through  the  new  aperture;  the  due  tus  ad  nares,  both  in  this 
and  the  preceding  state,  is  not  otherwise  diseased,  than  by  the 
thickening  of  its  lining. 

In  the  fourth,  the  passage  from  the  saccuius  lachrymalis  in 
the  nose  is  totally  obliterated,  the  inside  of  the  former  being  either 
ulcerated,  or  filled  up  with  a  fungus,  and  attended  sometimes  with 
a  caries  of  the  bone  underneath. 

These  will,  I  think,  comprehend  every  state  and  circumstance 
ef  the  disease,  and,  if  attended  to,  will  in  general  point  out  the 
proper  method  of  treating  it. 

The  ancients,  who  supposed  this  disorder  in  its  first  state  to  be 
an  inflammatory  defluxion  from  the  brain  on  the  caruncle  tending 
to  suppurate,  directed  their  first  attention  to  prevent  such  conse- 
quence; for  vphich  purpose  they  employed  phlebotomy,  cathartics, 

VOL.  I.  B  b 


194  OBSERVATIONS    ON   THE 

issues,  setons,  collyria,  and  refrigerant  applications  of  all  sorts;*^ 
and  these  not  succeeding,  they  had  recourse  to  such  as  they  thought 
would  hasten  the  suppuration  of  the  supposed  abscess.^ 

<=The  old  writers  have  many  forms  of  collyria,  epithems,  &c.  which  they 
used  upon  this  occasion,  but  issues  and  setons  they  lay  great  stress  on,  which 
practice  may  immediately  satisfy  us  what  was  their  opinion  of  the  nature  of 
the  disease. 

"  Omnium  vero  praestantissimum  est  setaceum,  materiam  enim  ad  oculos 
"  fluentem  potenter  ad  se  trahit  et  evacuat,  caput  ab  omnibus  excremen- 
"  titiis  humoribus  expurgat,  et  egregie  coroborat;  quid  plura,  tanti  est 
"  momenti  ut  inveleratam  fistulam  lachrymalem  sine  hoc  prsesidio  vix  curari 
"  posse." 

Mr.  Serjeant  Wiseman  most  certainly  did  not  understand  this  disease; 
and  mistook  it  either  for  a  tumor  of  the  encysted  kind,  or  for  an  inflam- 
matory defluxion,  and  treated  it  as  such:  his  words  are — 

"  -Eirylops  is  a  tumor  of  the  inner  canthus  of  the  eye,  either  scrophulous, 
"  xtheromatous,  or  of  the  nature  of  a  meliceris,  or  sometimes  with  inflamma- 
"tion:  the  causes  of  ^gylops  are  the  same  that  produce  the  like  tumor  in 
"  other  places,  but  sometimes  it  is  made  by  fluxion,  and  appeareth  first  as  a 
"  phlegmon:  if  it  be  struma  or  atheroma,  it  is  made  by  congestion." 

"  The  indications  of  cure  are  taken  from  the  JEgylops,  whether  it  be  in  its 
"  beginning  with  inflammation,  or  by  congestion,  passing  its  matter  forth 
*'  under  the  cllium'  into  the  e3^e,  in  which  case  it  is  fistulated.  Anchylops 
"  has  also  its  peculiar  way  of  treating,  as  other  tumors  of  the  glands." 

Without  any  design  to  criticise  on  the  strange  unintelligibility  of  the 
Serjeant's  language,  I  believe  I  may  venture  to  say,  that  no  man  who  is  not 
previously  acquainted  with  the  nature  of  the  disease,  will  learn  from  hence 
that  its  seat  is  in  the  lachrymal  sac,  and  that  an  obstruction  in  the  nasal  duct 
is  the  first  cause  of  it. 

To  come  still  nearer,  or  even  into  our  own  time,  Dr.  Daniel  Turner  com- 
piled a  treatise  of  surgery,  which  was  universally  dispersed  and  read  all  over 
the  kingdom,  and  was  at  that  time  generally  looked  upon  as  a  true  represen- 
tation of  the  London  practice:  the  Doctor  says,  •'  Anchylops  or  -Eg3dops  are 
"  diseases  of  the  internal  canthus  of  the  eye,  in  which  the  lachrymal  gland  is 
"  concerned,  and  from  whence  the  fistula  of  the  same  part  is  denominated: 
"  the  prognostic  may  be  gathered  from  the  method  of  cure,  in  which  uni- 
"  versals  premised,  such  as  bleedings,  purgings,  &,c.  you  may  attempt  to 
"  dissolve  the  humour  by  some  gentle  anodyne,  or  discutient  cataplasm;  but  if 
"  it  inflame  and  suppurate,  you  must  hasten  maturation,  as  well  as  the  dis- 
"  charge,  by  reason  of  the  part  it  lies  upon  j  but  when,  notwithstanding  ali 
"  your  endeavours  to  incarn  and  agglutinate,  the  matter  continues  to  dis- 
"  charge  itself,  not  only  by  the  outward  orifice,  but  also  under  the  cilium 
"  into  the  eye,  you  must  try  some  more  powerful  desiccative." 

I  believe  no  one  will  venture  to  say,  that  the  nature  and  seat  of  the 
disease  are  more  or  better  explained  by  what  the  Doctor  has  said,  than  by  the 


FISTULA  LACHRYMALI3.  195 

By  the  improper  use  of  medicines  of  the  latter  kind,  it  fre- 
quently happened  that  the  skin  became  inflamed  and  bruised;  the 
discharge  which  necessarily  followed  this  accident,  together  with 
the  heated  appearance  of  the  parts  about,  confirmed  tbtir  opinion 
of  a  collection  of  matter  within;  and  according  to  such  supposi- 
tion, they  attempted  to  obtain  a  cure  by  dilating  the  orifice,  and 
endeavouring  to  make  an  incarnation  from  the  bottom  of  the 
hollow:  not  being  acquainted  with  the  situation  or  use  of  the 
nasal  duct,  they  took  no  care  to  free  it  from  the  obstruction  under 
which  it  laboured,  but  dressing  the  sore  like  a  common  impos- 
thumation,  permitted  it  either  to  be  filled  up  with  a  loose  fungus, 
or  to  contract  itself  to  a  narrow  fistulous  orifice,  which  daily 
discharging  a  discoloured  kind  of  fluid,  and  not  healing  by  such 
means  as  they  made  use  of,  they  concluded  the  bone  underneath 
was  carious,  and  made  way  down  to  it,  either  by  removing  the 
parts  with  a  cutting  instrument,  or  by  destroying  them  with  caustic 
and  cautery,  intending  to  procure  an  exfoliation,  and  thereby  a 
firmer  basis  to  heal  on.s 

But  since  the  use  of  the  ductus  nasalis  has  been  known,  since 
it  has  been  discovered  that  an  obstruction  in  this  is  the  primary 
and  principal  cause  of  the  disorder,  and  that  what  passed  for  the 
cavity  of  an  abscess  is  really  the  sacculus  lachrymalis,  both  the 
intention  of  cure  and  the  means  have  been  considerably  altered. 

Serjeant  j  and  I  think  it  is  perfectly  clear  thkt  neither  of  them  hnd  any  true 
idea  of  it  at  all:  they  botli  mistook  the  caruncle  fov  the  lachrymal  gland,  and 
the  disease  for  an  encysted,  or  a  scrophulous  tumor,  which  ought  to  be 
brought  to  suppuration  ;  the  lachrymal  sac,  the  ductus  ad  nares,  their  use, 
and  the  disorder  of  them  creating  the  complaint  in  question,  they  were  totally 
unacquainted  with. 

8  Humulo  summum  ejus  foraminis  excipiendum,  et  totum  id  cavum  sicut 
in  fistulis  dixi,  usque  ad  os  excidendum. 

Celscs, 

Corpus  id  quod  inter  angulum  usque  ad  abscessum  est  excoluimus,  et 
carnes  e  profundo  educimus ;  quod  si  igitur  per  summa  ruptus  fuerit  ab- 
scessus,  totum  id  quod  eminet  usque  ad  os  excidendum. 

PAt'itrs. 

Si  vero  perhaec  medicamenta  non  curetur,  aut  recediraret  poslea,  signum 
est  quod  OS  est  corruptum  de  subtus,  quare  tunc  oportet  locum  detegl  et  os, 
corruptum  removeri. 


196  OBSERVATIONS  ON  THE 

In  the  first  and  most  simple  state  of  the  disease,  viz.  that  of 
mere  obstruction  without  inflammation,  much  pains  have  been 
taken  to  restore  the  parts  to  their  natural  state  and  use,  without 
making  any  wound  or  division  at  all;  the  introduction  of  a  probe, 
the  injection  of  a  fluid,  and  a  constant  compression  made  on  the 
outside  of  the  sacculus  in  the  corner  of  the  eye,  are  the  principal 
means  by  which  this  has  been  attempted. 

Some  [ew  years  ago  M.  Anel  made  a  probe  of  so  small  a  size 
as  h>  be  pable  of  passing  from  the  eye-lid  into  the  nose,  being 
introduced  at  one  of  the  puncta  lachrymalia,  and  passing  through 
the  sacculus  and  duct;  with  which  probe  he  proposed  to  break 
through  any  small  obstruction  which  might  be  found  in  its  pass- 
age. 

He  also  invented  a  syringe  whose  pipe  is  small  enough  to  en- 
ter one  of  the  puncta,  and  by  that  means  to  furnish  an  opportunity 
of  injecting  a  liquor  into  the  sacculus  and  duct;  and  with  these 
two  instruments  he  pretended  to  be  able  to  cure  the  disease 
whenever  it  consisted  in  obstruction  merely,  and  the  discharge 
was  not  much  discoloured.  The  first  of  these,  viz.  the  passage 
of  a  small  probe  through  the  puncta,  has  a  plausible  appearance, 
but  will,  upon  trial,  be  found  very  unequal  to  the  task  assigned: 
the  very  small  size  of  it,  its  necessary  flexibility,  and  the  very 
little  resistance  it  is  capable  of  making,  are  manifest  deficiencies 
in  the  instrument;  the  quick  sensation  in  the  lining  of  the  sac  and 
duct,  and  its  diseased  state,  are  great  objections  on  the  side  of 
the  parts,  supposing  that  it  was  capable  of  answering  any  valua- 
ble end,  which  it  most  certainly  is  not. 

That  the  passing  a  fine  probe  from  one  of  the  puncta  lachry- 
malia into  the  nose  is  very  practicable,  I  know  from  experience; 
but  I  also  know  from  the  same  experience,  that  the  pain  it  gives, 
and  the  inflammation  it  often  excites,  are  much  greater  than  any 
benefit  which  does  or  can  arise  from  it. 

It  is  said  that  the  principal  use  of  this  probe  is  to  clear  the  lit- 
tle ducts  leading  from  the  puncta  into  the  sacculus,  and  the  ob- 
struciion  of  those  ducts  is  often  mentioned  as  a  part  of  this 
disease;  by  which  one  would  be  led  to  suppose  that  it  was  a  cir- 
cumstance which  frequently  occurred,  whereas  it  is  seldom  or 
uever  met  with,  and  when  it  does  happen,  can  never  produce  the 


FISTULA  LACHRYMALIS.  19*^ 

disease  in  question,  the  principle  characteristic  of  which  is,  a  dis- 
charge into  the  inner  corner  of  the  eye  upon  pressure  made  in  the 
angle:  this  discharge  is  made  from  the  sacculus,  through  the  punc- 
ta,  and  proves  that  the  latter  are  open.  The  passing  a  probe  there- 
fore through  these  seems  to  be  perfectly  unnecessary,  since  a 
stoppage  of  them  would  never  give  rise  to  that  disease,  which  con- 
sists in  an  obstruction  to  the  passage  of  any  thing  from  the  sac 
into  the  nose,  and  not  from  the  eye  into  the  sac. 

The  syringe,  if  used  judiciously  while  the  disease  is  recent,  the 
sac  very  little  dilated,  and  the  mucus  perfectly  clear,  will  some- 
times be  found  serviceable:  I  have  used  it  where,  I  think,  it  has 
been  much  so;  I  have  by  means  of  it  injected  a  fluid  through  the 
sacculus  into  the  nose,  and  in  two  or  three  instances  have  effected 
cures  by  it:  but  I  have  also  often  used  it  ineffectually;  it  gives  no 
pain,  and  a  few  trials  render  the  use  of  it  very  little  troublesome. 

Fabritius  ab  Aquapendente  invented  an  instrument,  which  was 
so  contrived,  as  by  means  of  a  screw  to  make  a  pressure  exter- 
nally on  the  lachrymal  bag,  from  the  use  of  which,  he  says,  his 
patients  received  much  benefit:  this  instrument  has  been  consider- 
ably improved  by  late  practitioners,  and  is  still  recommended  as 
very  useful. 

All  the  good  that  can  be  obtained  by  compress  and  bandage, 
this  screw  is  capable  of  procuring;  but  it  is  also  subject  to  all  the 
same  inconveniencies,  arising  from  the  impossibility  of  determin- 
ing exactly  the  due  degree  of  pressure:  for  if  it  be  so  great  as  to 
bring  the  sides  of  the  upper  part  of  the  sac  into  contact,  all  com- 
munication between  it  and  the  puncta  will  be  thereby  siopt:  if  it. 
be  but  slight,  the  accumulation  will  not  be  prevented,  nor  does  it 
in  either  case  contribute  to  the  removal  of  the  obstruction  in  the 
nasal  duct,  the  primary  and  original  cause  of  the  disease. 

If  the  curative  intention  was  to  procure  an  union  of  the  sides 
of  the  sacculus,  as  in  the  case  of  parts  separated  from  each  other 
by  the  formation  of  matter  or  sloughs,  and  the  pressure  could  be 
made  uniformly  and  constantly,  possibly  it  might  be  so  managed 
as  to  answer  a  valuable  purpose:  bui  as  that  is  not  the  intention, 
the  pressure,  whether  made  by  an  instrument,  or  by  a  common 
roller  and  compress,  contributes  little  or  nothing  toward  a  cure, 


198  OBSERVATIONS  ON  THE 

nor  did  I  ever  see  one  effected  by  it,  although  I  have  several 
times  tried  both. 

That  some  slight  obstructions  of  the  nasal  duct  have  gone  off 
while  the  compression  has  been  used,  I  do  not  deny;  but  am  in 
great  doubt  concerning  the  share  which  it  had  in  removing  them, 
having  seen  more  than  one  instance  of  a  cure  being  obtained  by 
the  use  of  a  proper  regimen  and  medicines,  in  slight  and  recent 
cases,  where  nothing  is  used  externally  but  a  vitriolic  collyriom; 
and  having  been  always  disappointed  in  my  attempts  at  mere 
bandage  of  any  kind. 

Besides  these  means  of  attempting  a  cure  without  incision,  the 
gentlemen  of  the  French  Academy  have  favoured  us  with  some 
others,  such  as  the  introduction  of  a  probe  into  the  lower  part  o^ 
the  nasal  duct  within  the  nose,  the  injection  of  a  fluid  by  the  same 
orifice,  the  passing  a  seton  from  the  punctum  lachrymale  superius 
through  the  sacculus  and  duct,  and  out  at  the  nostril,  there  to  re- 
main till  the  cure  is  completed;  and  for  those  purposes  they  have 
invented  and  given  figures  of  a  number  of  probes,  syringes,  and 
many  other  instruments,  which,  they  say^  have  been  very  success- 
fully used:  far  be  it  from  me  to  say  that  they  have  not,  or  to  pre- 
vent any  body  from  trying  those,  or  any  other  means  by  which 
mankind  may  be  cured  of  diseases  with  the  least  possible  fatigue 
and  pain;  but  from  the  experiments  which  I  have  made  of  most 
of  these  processes,  I  must  beg  leave  to  suspend  my  assent  to  their 
general  utility,  or  even  to  their  frequent  practicability. 

Repeated  trials  upon  dead  subjects  will  undoubtedly  enable  a 
-man  to  pass  the  probe,  or  perhaps  now  and  then  the  seton,  but  he 
xvill  also  find  it  often  absolutely  impracticable;  and  in  the  few  in- 
stances in  which  he  may  chance  to  succeed  as  to  this  attempt, 
what  will  in  general  be  the  consequence?  not  what  the  writers  on 
these  subjects  have  taught  him  to  believe,  a  cure,  but  a  sense  of 
pain  and  degree  of  inflammation,  which  the  patient,  before  such 
attempts  were  made,  was  free  from — an  exasperation  of  the  dis- 
ease, and  a  loss  of  much  time,  as  I  have  more  than  once  experi- 
enced. To  which  consideration  may  be  added,  that  infanls  and 
young  children  are  very  often  afflicted  with  this  disorder,  and  that 
such  processes  as  these  are  absolutely  impracticable  upon  them. 

I  should  be  very  sorry  to  be  misunderstood  in  what  I  now  say, 


FISTULA  LACHRYMALIS.  199 

to  have  it  suspected,  that  I  mean  to  derogate  from  the  character 
of  those  gentlemen  who  have  been  the  inventors  of  these  opera- 
tions, or  that  I  speak  slightingly  of  them,  either  because  they  are 
not  my  own,  or  because  I  have  not  been  able  to  succeed  in  the 
use  of  them:  it  would  give  me  great  concern  if  I  thought  it  would 
be  believed  that  I  acted  upon  so  mean,  so  narrow  a  principle;  nO 
man  is  or  would  be  more  pleased  with  any  real  improvement  in 
our  art  than  myself;  but  having  taken  all  the  pains  in  my  power 
to  apply  the  discoveries  of  which  I  am  now  speaking  to  practice, 
(the  only  test  of  good  surgery,)  and  having  found  them  most  fre- 
quently impracticable,  always  ineffectual,  I  think  myself  obliged 
to  say  so. 

Anel's  syringe  I  have  used  successfully,  and  think  it  may  now 
and  then  be  very  well  worth  trying,  in  recent  cases  more  espe- 
cially, as  it  may  always  be  used  without  giving  any  pain  or  run- 
ning the  risk  of  raising  an  inflammation;  but  I  must  also  beg 
leave  to  observe,  that  if  the  bag  is  not  much  dilated,  the  mucus 
clear,  the  skin  and  cellular  membrane  uninflamed,  and  the  parts 
about  soft  and  easy,  if  the  patient  will  take  care  not  to  suifer  too 
great  an  accumulation,  will,  by  the  frequent  use  of  a  vitriolic  col- 
lyrium,  keep  the  eye-lids  clean  and  cool,  and  carefully  avoid  such 
things  as  irritate  the  membrana  narium,  or  occasion  a  sudden 
flux  of  lymph  from  the  lachrymal  gland,  the  disease  may  for  many 
years,  nay  often  for  life,  be  kept  from  being  very  troublesome  or 
inconvenient,  without  any  surgery  at  all. 


SECT.  V. 

When  the  disease  is  got  beyond  the  simple  state  just  described, 
that  is,  when  the  parts  round  about  are  much,  or  constantly  in- 
flamed, or  the  skin  covering  the  tumor  is  burst,  there  is  something 
more  to  be  done  if  a  cure  be  intended. 

In  this  state  an  opening  in  the  upper  part  of  the  sacculus  lachry- 
malis  becomes  in  general  absolutely  necessary;  and  as  a  wound 
made  by  a  knife  leaves  a  much  less  disagreeable  scar,  than  that 
which  necessarily  follows  the  bursting  of  the  skin,  one  being  a 


200  OBSERVATIONS  ON  THE 

Caere  simple  division,  the  other  a  loss  of  substance,  it  will  always 
be  found  best  to  anticipate  the  accident  of  bursting,  by  making 
the  opening  as  soon  as  the  integuments  are  in  such  a  state  as  to 
threaten  it/ 

For  the  making  this  incision  authors  have  been  very  particular 
in  their  direction  with  regard  to  its  place,  manner,  and  form:  they 
have  ordered  it  to  be  semilunar,  having  its  concave  part  toward 
the  eye,  and  that  the  point  of  union  of  the  lids  should  be  exactly 
opposite  to  the  centre  of  the  incision.  This  lunated  figure  was 
calculated  to  correspond  with  the  course  of  the  fibres  of  the  orbi- 
cular muscle,  upon  a  supposition  that  a  transverse  section  of  them 
would  produce  an  inversion  of  the  lower  lid,  an  effect  which  never 
follows.  All  that  the  surgeon  need  observe  is,  to  take  care  to 
keep  the  knife  at  a  proper  distance  from  the  juncture  of  the  pal- 
pebree,  to  begin  the  incision  a  very  little  above  a  line  drawn  from 
that  juncture  toward  the  nose,  and  to  continue  it  downward:  its 
form  may  full  as  well  be  straight  as  any  other,  and  the  best  in- 
strument to  make  it  with  is  a  small  crooked  bistoury. 

If  the  sacculus  is  already  burst,  the  place  of  opening  is  deter- 
mined, and  the  orifice  may  be  enlarged  with  a  knife,  or  di- 
lated. 

The  incision  made,  the  sacculus  should  be  moderately  distend- 
ed, either  with  dry  lint,  or  a  bit  of  prepared  sponge;  by  which 
means  an  opportunity  will  be  gained  in  two  or  three  days  of 
knowing  the  state  of  the  inside  of  the  sac,  and  of  the  ductus  na- 
salis:  if  the  former  is  neither  sloughy  nor  otherwise  diseased,  and 
the  obstruction  in  the  latter  but  slight,  it  sometimes  happens,  that 
after  a  free  discharge  has  been  made  for  some  days,  and  the  in- 
flammation occasioned  by  the  first  operation  is  gone  off,  the  sac 

f  I  cannot  but  be  of  opinion,  that  in  this  case,  and  many  othei*  abscesses,  the 
opening  which  nature  makes  from  witliin  generally  heals  with  less  scar  or 
mark  than  that  which  is  made  by  a  cutting  instrument.  It  is  certainly  in 
many  cases  wrong  to  let  matter  remain  after  it  is  palpably  formed;  as  in 
some  situations  it  is  capable  of  doing  injury  to  the  parts  on  which  it  is  situat- 
ed. I  only  mean  to  say,  that  when  matter  may  be  safely  left  till  it  makes  its 
own  way  out,  the  scar  is  not  so  visible  as  when  an  opening  is  artificially 
made;  as,  except  in  those  cases  where  from  violent  inflammation  and  disten- 
sion a  sphacelus  is  induced,  the  natural  opening  is  rather  a  distraction.than 
a  destruction  of  fibres,  or  loss  of  substance.        E. 


FISTULA  LACHRYMALIS.  201 

contracts  itself,  a  superficial  dressing,  with  moderate  pressure, 
heals  the  sore,  the  lachrymal  fluid  resumes  its  wonted  course, 
and  the  disease  disappears. 

Of  this  I  have  seen  more  than  one  instance,  and  perhaps  it 
would  happen  oftener,  if  the  very  absurd  manner  in  which  this 
disorder  is  generally  treated  after  opening  the  bag,  did  not  pre- 
vent it:  in  this  state  success  is  to  be  expected  from  the  most  gen- 
tle treatment  only:  whatever  irritates,  inliames,  or  destroys,  will 
infallibly  prevent  it. 

If  this  simple  method  does  not  succeed,  or  from  the  state  of  the 
parts  seems  unlikely  to  do  so,  another  must  be  tried,  which  the 
opening  already  madfewill  enable  us  to  put  in  practice:  the  point 
to  be  aimed  at  is,  if  possible,  to  render  the  nasal  duct  pervious  to 
the  lachrymal  fluid;  and  we  must  endeavour  to  obtain  this  end  by 
such  means  as  give  the  least  pain,  excite  the  least  inflammation, 
and  leave  the  parts  as  near  as  possible  in  their  natural  state;  that 
is,  we  are  to  endeavour  to  dilate  the  passage  from  the  sac  to  the 
nose,  by  some  means  which  will  gradually  distend  it  without  de- 
stroying its  texture,  in  the  same  manner  as  the  dilation  of  the  ure- 
thra ought  to  be  effected  in  the  case  of  strictures,  by  passing  either 
a  probe,  or  a  piece  of  cat-gut,  or  a  bougie,  gently  into  it,  as  far 
as  it  will  easily  go,  and  repeating  it  occasionally  until  it  is  got 
quite  through  and  the  passage  is  free.^^ 

Every  man  will  determine  for  himself,  by  what  means  he  will 
endeavour  to  accomplish  this  end;  nor  is  it  of  very  material  con- 
sequence which  he  prefers,  provided  it  be  done  gradually,  and 
without  giving  pain:  a  proper  dilatation  of  the  upper  part  of  the 
sacculus  by  dry  lint,  or  a  bit  of  prepared  sponge,  will  be  found 
useful  previous  to  the  attempt  toward  passing  any  thing  into,  or 
through  the  duct;  and  it  will  also  be  necessary  that  the  surgeon 
be  possessed  of  a  just  idea  of  the  size  and  direction  of  it,  both  in 
a  natural  and  a  diseased  state;  for  whoever  has  formed  one  only, 

E  This  caution  is  very  necessary  to  be  observed  in  the  cure  of  strictures  of 
tlie  urethra,  in  which  case  the  proper  intention  is  gnulually  to  dilate  the  pass- 
age, and  to  procure  an  increased  discharge  of  mucus  from  the  lacuna:;  this 
should  always  be  done  gently,  and  by  means  which  give  as  little  pain  as  possi- 
ble; whatever  irritates  or  gives  pain  will  certainly  do  miscliief.  will  add  to 
the  obstruction!  and  increase  the  dysury. 
VOL.  I.  C   C 


202  OBSERVATIONS  ON  THE 

from  viewing  its  bony  channel  in  a  dry  scull,  will  upon  experi- 
ment find  himself  much  deceived  with  regard  to  its  diameter  in  a 
living  subject;  the  membrane  which  lines  it  is  not  extremely  thin, 
in  a  healthy  state,  and  when  it  is  inflamed  or  thickened  by  ob- 
struction, the  passage  through  the  duct  is  thereby  rendered  very 
small,  if  it  is  not  quite  shut  up. 

They  of  our  ancestors  who  mistook  this  disease  for  an  abscess, 
and  found  (as  indeed  they  always  must)  extreme  difficulty  in  filling 
it  up  with  sound  flesh,  generally  had  recourse  to  escharotic  medi- 
cines for  the  destruction  of  that  fungus  which  seemed  to  hinder 
them  from  accomplishing  their  end;  by  which  conduct  they  irri- 
tated all  the  neighbouring  parts,  increased  the  inflammation,  and 
were  most  frequently  frustrated  in  their  expectation  of  a  cure  at 
l?ist.  The  same  kind  of  medicines  were  also  used  by  those  who 
supposed  the  disorder  to  be  an  encysted  tumor,  with  intention  to 
eradicate  the  cyst,  which,  they  thought,  prevented  a  cure  by  re- 
maining behind;  9nd  both  these  methods  of  practice  were  vindi- 
cable,  supposing  their  idea  of  the  disease  had  been  a  true  one, 
which  it  most  undoubtedly  was  not:  their  reasoning  was  right,  but 
their  principles  were  wrong;  they  were  in  general  very  little  ac- 
quainted with  the  structure  and  use  of  the  parts,  and  totally  mis- 
took the  nature  of  the  disease. 

But  now,  that  we  are  thoroughly  acquainted  with  both,  this  kind 
of  practice  ought  surely  to  cease,  as  the  preservation  of  the  sac- 
culus  and  duct,  and  not  their  destruction,  are,  or  ought  to  be  in- 
tended: ail  cathasretic  medicines  must  be  wrong  and  prejudicial, 
at  least  while  the  intention  is  such;  an  intention  at  all  times 
rational,  and  sometimes  capable  of  being  fulfilled. 

Notwithstanding  the  destruction  of  the  bag  is  allowed  to  be 
lyrong  by  most  surgeons  of  the  present  tiaie,  yet  there  are  many, 
who,  by  their  manner  of  dressing  it,  after  they  have  opened  it,  do 
really,  thought  not  intentionally,  produce  the  same  effect  as  our 
forefathers  aimed  at:  it  is  still  a  custom  with  many,  as  soon  as  it 
is  opened,  to  distend  the  cavity  of  it  with  a  hard  tent,  or  with  dos- 
sils of  lint  charged  with  escharotic  medicines,  such  as  mercurius 
precipitatus  ruber,  &c.  by  which  means  the  inflammation  is  in- 
creased, the  skin  and  edges  of  the  incision  hardened,  and  the 
inside  of  the  sacculus  put  under  the  necessity  of  casting  off  a 


FIStliLA  LACHRYMALIS.  20^ 

slough.  This  is  one  of  several  instances  still  remaining  of  our  ad- 
hering to  old  methods  of  practice,  after  the  principles,  on  which 
such  methods  were  originally  formed,  have  been  allowed  even  by 
ourselves  to  be  erroneous;  for  this  manner  of  dressing  the  sore  is 
effectively  the  same  as  the  ancients  made  use  of,  while  they  sup- 
posed the  disease  to  be  an  abscess  of  the  caruncle,  and  encysted 
tumor,  or  a  callous  ulcer  with  carious  bone;  and  was  by  them  in- 
tended very  properly  for  the  destruction  of  such  callosity,  to  assist 
the  exfoliation  of  the  supposed  caries,  and  to  procure  a  firm  basis 
to  incarh  upon. 

On  the  contrary,  the  point  which  ought  first  to  be  aimed  at,  im- 
mediately after  having  made  an  opening  into  the  sac,  is  to  endea- 
vour to  remove' the  obstruction  of  the  natural  passage  from  thence 
into  the  nose,  by  the  means  already  mentioned,  which  design  this 
method  of  cramming  in  escharotic  dressings  must  necessarily  frus- 
trate, must  frequently  render  a  simple  case  complex,  and  at  least 
retard  that  cure  it  is  designed  to  expedite. 

The  only  excuse  that  can  be  now  made  for  such  method  of 
dressing  is,  that  the  surgeon  is  satisfied  that  the  ductus  ad  nares 
cannot  be  restored  to  its  use,  and  therefore,  by  destroying  part  of 
the  sacculus,  intends  to  procure  such  a  generation  of  new  flesh,  as 
may  fill  up  its  cavity,  and  hinder  the  accumulation  or  lodgement 
there  in  future. 

If  this  was  feasible,  perhaps  it  might  be  a  vindication  of  such 
treatment;  but  unfortunately  it  neither  is,  nor  can  be  so  in  gene- 
ral; and  whoever  will  attentively  examine  the  natural  situation 
and  structure  of  the  parts  concerned,  will  immediately  see  why  it 
cannot.  All,  or  the  greatest  part  of  the  diseased  and  obstructed 
duct,  lying  in  its  bony  channel  out  of  the  reach  of  what  is  applied 
to  the  inside  of  the  sacculus,  must  prevent  the  generation  of  a  firm 
basis  at  its  bottom,  and  produce  a  fresh  collection  of  mucus,  which 
in  a  short  space  of  time  lifts  up  the  cicatrix  into  a  new  tumor,  and 
requires  the  same  treatment  as  if  nothing  at  all  had  been  done. 

On  the  other  hand,  it  must  not  be  denied,  that  now  and  then  a 
cure  has  by  this  means  been  effected;  but  it  has  been  so  rarely, 
that  it  can  hardly  be  admitted  as  an  authority  or  vindication  of  so 
irrational  an  attempt. 

The  parts  about  the  eye  are  most  of  them  of  very  quick  sensa- 


204  OBSERVATIONS  ON  THE 

tion,  and  easily  irritated;  all  dressings  are  in  fact  extraneous 
bodies,  and  therefore,  when  applied  to  such  parts,  cannot  be  too 
soft  and  light:  suppuration  is  an  act  of  nature,  not  of  art;  and  is 
always  best  executed  when  she  is  least  disturbed:  this  is  a  general 
truth,  and  will  hold  good  in  all  parts  of  the  body,  even  where 
suppuration  may  be  most  wanted:  but  in  the  present  case,  in 
Tvbich  the  lower  part  of  the  sac,  and  all  the  duct,  are  often  in  such 
state  as  not  to  require  any  suppuration  at  all,  escharotic  dress- 
ings of  any  kind,  by  producing  inflammation  both  of  the  eye  and 
caruncle,  by  rendering  the  edges  of  the  sore  hard  or  sloughy, 
and  by  destroying  the  communication  between  the  puncta  lach- 
rymalia  and  sacculus,  must  necessarily  counteract  the  only  proper 
intention  of  cure. 

1  would  not  in  this  place  be  thought  to  mean,  that  a  mere 
superficial  pledget  is  all  the  dressing  that  is  required:  no;  a  mode- 
rate dilatation  of  the  upper  part  of  the  sacculus  is  at  first  abso- 
lutely necessary,  in  order  to  get  easily  at  the  duct  below;  but  this 
should  be  effected  without  the  use  of  corrosive  applications  of  any 
kind,  and  is  best  accomplished  by  prepared  sponge,  which  will 
distend  to  almost  any  degree  wiihout  destroying. 

When  a  passage  has  been  once  obtained,  it  should  be  care- 
fully kept  open,  either  by  apiece  of  cat-gut,  a  small  bougie,  a 
leaden  probe,  or  something  of  that  sort;  and  when  it  is  thoroughly 
established,  the  sore  may  be  permitted  to  contract,  until  it  becomes 
no  more  tlwn  what  serves  for  the  introduction  of  the  bougie  into 
duct;  in  this  state  I  would  advise,  that  it  be  kept  open  for  some  time, 
injecting  now  and  then  a  little  aqua  calcis,  softened  with  mell. 
rosar.  through  from  above  into  the  nose;  and  when  it  appears  that 
the  passage  is  so  free,  and  so  well  established,  that  there  is  good 
probability  of  its  preserving  itself,  the  orifice  in  the  angle  of  the 
eye,  by  being  covered  only  by  a  superficial  bit  of  plaster,  or  pledget, 
will  contract  and  close;  and  if,  during  its  closing,  moderate  pres- 
sure be  used  on  the  sacculus,  to  prevent  a  fresh  accumulation  of 
mucus,  it  will  assist  the  cure. 

Whether  the  sacculus,  in  a  healthy  and  undilated  state,  is  endued 
with  any  degree  of  contractile  power,  which  it  loses  by  being 
distended,  or  to  what  other  cause  it  may  be  owing,  I  know  not;  but 
I  have  more  than  once  beeen  foiled  in  my  attempts  towards  this 


FISTULA  LACHRYMALIS.  205 

method  of  curing  the  disease,  by  a  fresh  collection  of  mucus, 
notwithstanding  the  nasal  duct  has  remained  open,  as  appeared  by 
the  discharge  made  into  the  nose  upon  pressure  on  the  tumor,  the 
immediate  subsidence  of  the  said  tumor,  and  the  passage  of  an 
injection,  or  small  probe,  after  having  again  opened  the  sac.  Some 
of  these  have,  upon  being  again  healed,  remained  good  cures,  and 
others  not;  the  uncertainty  which  attends  these  cases  is  great,  and 
the  event  never  to  be  know^n  but  by  experiment.  Whoever  says 
that  none  of  ihem  are  to  be  cured  by  the  foregoing  method,  errs 
as  much  as  he  would  who  should  expect  it  to  succeed  in  all. 
Where  the  disease  is  in  such  state  as  to  admit  its  being  tried,  it  is 
very  well  Tvorth  while,  as  it  is  not  painful  nor  tedious;  and  where 
it  does  not  answer  our  expectations,  it  is  no  hinderance  to  any 
other  more  efficacious  one  being  made  use  of  afterward:  in  all 
these  cases,  different  circumstances  in  the  patient,  or  in  the  state 
of  the  diseased  parts,  must  produce  a  variation  in  the  necessary 
treatment,  both  in  general  and  particular:  a  bad  habit  w-ill  require 
the  use  of  internal  remedies;  the  combination  of  other  diseases  of 
the  neighbouring  parts  will  add  to  the  difficulty  and  trouble;  and 
even  the  fairest,  and  such  as  seem  most  likely  to  succeed,  do  some- 
times resist  this,  and  indeed  every  other  attempt. 

From  the  necessity  of  keeping  the  eye  bound  while  dressings 
are  applied  for  the  dilatation  of  the  sacculus,  an  inflammation  is 
frequently  raised.  This,  added  to  the  necessary  discharge  of 
serum,  mucus,  &c.  is  apt  to  heat  and  excoriate  the  parts  about; 
therefore,  warm  fomentations,  cooling  collyria,  epulotic  cerates, 
and  renewing  the  dressings  as  often  as  shall  be  necessary,  with 
whatever  else  can  contribute  towards  keeping  the  skin  clean  and 
cool,  must  be  found  serviceable  as  well  as  pleasant,  and  should 
never  be  neglected . 


206  OBSERVATIONS  ON  THE 


SECT.  IV. 


The  last  state  which  I  mentioned  of  this  disorder  is  that  in 
which  the  natural  passage  from  the  sacculus  to  the  nose  is  so 
diseased  as  to  be  quite  obliterated,  or  in  which  the  bones  are 
sometimes  found  to  be  carious. 

The  methods  hitherto  described,  have  all  been  calculated  to  pre- 
serve the  natural  passage,  and  to  derive  the  lachrymal  fluid  again 
through  it:  in  this  attempt  they  are  sometimes  successful;  but 
when  they  are  not,  there  is  no  chirurgical  means  left,  but  to  at- 
tempt the  formation  of  an  artificial  one  in  its  stead. 

The  upper  and  hinder  part  of  the  sacculus  lachrymalis  is  firmly 
attached  to  the  os  unguis,  a  small  and  very  thin  bone  just  within 
the  orbit  of  the  eye;  which  bone  is  so  situated,  that  if  it  be  by  any 
means  broken  through,  or  removed,  the  two  cavities  of  the  nose 
and  of  the  orbit  communicate  with  each  other,  consequently  the 
OS  unguis  forms  the  partition  between  the  hinder  part  of  the  lach- 
pymal  bag,  and  the  upper  part  of  the  cavity  of  the  nose;  and  it  is 
by  making  a  breach  in  this  partition  that  we  attempt  the  forma- 
tion of  an  artificial  pr.ssage  for  the  lachrymal  fluid. 

This  operation,  if  considered  merely  as  a  perforation,  is  no  in- 
vention of  the  moderns;  the  ancients  undoubtedly  performed  it: 
but  though  it  was  executed  much  in  the  same  manner  as  it  is  now^ 
yet  it  was  not  done  with  the  same  intention. 

From  the  accounts  which  our  ancestors  have  left  us  of  the  dis- 
ease in  question,  it  is  plain,  that  they  supposed  it  to  be  always  at- 
tended with  a  degree  of  callosity,  and  often  with  caries,  and  that 
the  surest  way  to  obtain  a  cure  was  to  lay  the  bone  bare:  this 
they  effected  either  by  caustic  or  cautery,  according  to  the  hu- 
mour of  the  surgeon,  or  the  fears  of  the  patient.  If  caustic  appli- 
cations vv'ere  used,  they  waited  the  separation  of  the  eschar;  and 
if  they  found,  or  believed  the  bone  to  be  altered,  they  applied  an 
actual  cautery  to  it:  if  the  bone  to  which  the  iron  was  applied 
was  the  os  unguis,  it  was  too  thin  to  bear  much  heat,  or  much 
pressure,  consequently  was  easily  burnt,  or  broke  through,  and 
by  that  means  an  opening  was  made  into  the  nose;  a  terebra  was 


FISTULA  LACHRyMAUS.  207 

Stiso  sometimes  made  use  of  instead  of  cautery,  and  the  same  ef- 
fect produced  thereby.'* 

By  each  of  these  methods,  a  passage  being  made  from  the  sac- 
culus  lachrymalis  into  the  nose,  a  cure  was  sometimes  accident- 
ally obtained;  but  the  cautery  was  applied,  either  to  destroy  the 
supposed  callosity,  or  to  desquamate  a  caries;  and  the  terebra, 
either  for  the  same  reason,  or  to  make  a  passage  for  the  discharge 
of  matter,  which  lodged,  and  as  they  thought  hindered  the  heal- 
ing of  the  sore;  for  as  they  were  not  acquainted  with  the  natural 
passage  of  the  lachrymal  fluid,  it  would  be  absurd  to  suppose,  that 
by  means  of  this  perforation  they  intended  .the  formation  of  an 
artificial  one.  Callosity  and  caries  were  their  two  characteris- 
tics of  the  disease;  the  dissolution  of  one,  and  the  exfoliation  of 
the  other,  were  all  they  had  in  view  from  the  use  of  either  caus- 
tic or  cautery,  and  the  perforation  of  the  os  unguis  was  either 
accidental,  or  made  merely  for  the  discharge  of  matter.' 

Indeed,  if  we  attentively  consider  what  the  old  writers  have 
left  us  on  this  subject,  it  will  appear,  that  though  they  knew  that 

i"  Oculo  et  caeteris  junctis  partibus  bene  obtectis,  os  ferramento  adurendum 
est  vehementius  :  quod  si  jam  carie  vexatum  est,  quo  crassior  huic  squama 
abscedat,  quidam  adurentia  irnponunt.  Celsus. 

Cum  islo  pulvere  in  veritate  fere  mortificabam  omnes  fistulas  curabiles,  et 
cum  cauterio  ferreo,  aut  aeneo — facia  mortificatione  tali  totius  carnis  usque 
ad  OS,  cum  pulvere  aut  unguento  superdictissuperpone  mortificato  but3'rum 
et  eschara  aspice,  et  si  fuerit  os  corruptum  cauteriza  ipsiim  usque  ad  ejus 
profundum.  Gvl.  dk  Saliceto. 

Postea  si  homo  fuerit  delicatus,  per  istud  foramen  mittatur  Canelius  ferreus 
vel  sneus  subtilis  usque  ad  profundum  si  poteris,  et  per  ipsum  canellum  fer- 
rum  candens  immitte  et  §stulce  radices  decoque  :  at  si  timuerit  ign^m  immita- 
tur  pillula  de  unguento  ruptorio.  Rolandus. 

Osse  detecto  ferrum  imprime  calidum  supra  ipsum,  et  ipsum  cauterium 
niediocriter  comprimendo,  postea  imple  totum  vulnus  cum  oleo  rosarum 
misto  cum  vitello  ovi.  Laxjeajtc. 

•Fabritius  ab  Aquapendente,  who  in  general  copies  Paulus,  speaks  of  the 
perforation  as  meant  only  to  make  a  depending  orifice  for  matter,  "  Post  car- 
"  unculx  et  loci  excisionem,  terebra  humorem  aut  pus  in  nares  derivarint." 

Fab.  ab   AaUAPENDESTE. 

Gul.  de  Saliceto,  and  indeed  many  other  of  the  ancient  writers,  speak  of 
using  both  cautery  and  terebra  to  the  purpose  of  deriving  the  matter  and  sa^ 
nies  which  lodge  in  the  sac,  into  the  nose ;  and,  by  making  a  depending  ori- 
tce,  to  procure  a  firm  basis  to  heal  on.  "  Aspice  os,  et  si  fuerit  corruptum 
*'  cauteriza  ipsum  usque  ad  ejus  profuuduip,  et  concavitatsm  cum  cauterio 


208  OBSERVAXIONS  ON  THE 

a  passage  into  the  nose  was  sometimes  a  consequence  of  their 
use  of  the  terebra  and  cautery,  yet  the  operators  had  no  very  ac- 
curate knowledge  of  the  parts  they  made  so  free  with;  no  precise 
idea  of  the  bone  on  which  their  instruments  were  applied,  or 
through  which  they  passed;  nor  of  the  place  most  immediately 
proper  for  such  application  of  them:  sometimes  they  perforated 
the  OS  unguis  very  properly,  sometimes  the  cautery  or  terebra  was 
thrust  into  the  bony  channel  of  the  natural  nasal  duct,  and  some- 
times they  were  applied  to  the  nasal  process  of  the  maxillary  su- 
perior: the  direction  given  by  most  of  them  to  rasp  the  bone 
(scalpris  abradere)  and  to  impress  the  cautery  with  some  force, 
that  the  bone  may  be  sooner  exfoliated,  [ut  citius  squama  absce- 
dat,)  plainly  prove,  that  either  they  were  not  aware  of  the  tender 
structure  of  the  os  unguis,  or  that  they  did  not  intend  to  apply 
their  instruments  to  it:  if  the  former  was  the  case,  the  perfora- 
tion was  accidental;  if  the  latter,  they  must  have  often  done  much 
more  harm  than  good;  that  is,  they  must  have  burned  and  de- 
stroyed unnecessarily,  parts  which  have  little  or  nothing  to  do  with 
the  disease;  and  by  such  treatment  of  them  must  have  much  of- 
tener  prevented  than  accomplished  a  cure> 

The  intention  of  the  present  practitioners  in  making  this  per- 

"  punctuali,  et  perfora  ipsum  ad  aliam  partem,  ejus  ut  sanies  per  nasum  fluat, 
*'  deinde  incarnetur  et  consolidetur."  Gul.  de  Salickto. 

Indeed,  the  formation  of  an  ai-tificial  passage  for  the  laclirymal  fluid  could 
make  no  part  of  the  intention  of  those  who  were  not  rightly  acquainted  with 
the  natural  one. 

Paulus  mentions  perforation  with  the  terebra  as  the  practice  of  some  in 
his  time ;  but  from  what  he  says,  it  is  plain  he  did  not  practise  it  liimself, 
or  think  it  necessary,  and  that  he  regarded  it  only  as  a  method  of  making  a 
depending  orifice ;  his  words  are,  "  Quod  si  jam  carie  vexalum  est,  ferro 
candenti,  acuto,  ac  in  cuspidem  abeunte  adurimus  spongia  frigida  madente 
oculo  imposita. 

"  Sunt  qui  post  carunculse  exclsionem  terebra  usi  humorem  aut  pus  in  nares 
«'  derivarint ;  nos  autem  satis  habuimus  eousque  solum  ferramentis  ad  ^Egy- 
"  lopem  accommodatis  adurere  ut  squama  abscederet." 

Paulus  .SIgineta. — See  also  Fab.  ab  AauAPKjfniJSTE. 

•t  Petrus  de  Marchetti,  though  perfectly  sensible  that  the  os  unguis  was 
often  broken  through  by  the  cautery,  yet  insists  upon  it,  that  it  served  no 
other  purpose  than  to  hasten  exfoUation.  "  Prxterquam  quod  hujus  perfora- 
"  tionis  non  alius  sit  usus  quam  ut  os  perforatum  aut  inustum  citius  abscedat. 
"  Observandum  tamen  non  esse  perforandum  os  nisi  pr^sente  maxima  ipsius 


nSTULA  LACHRYMALIS.  209 

foration  is  different  from  that  of  our  ancestors;  but  it  is  more 
National,  and  founded  upon  the  nature  and  use  of  the  parts  con- 
cerned in  tlie  disease:  it  is  to  form  and  maintain  a  new  artificial 
passage  from  the  lachrymal  bag  into  the  nose,  when  the  natural 
one  can  no  more  be  rendered  useful,  and  without  any  view  to  any 
thing  else:  this,  I  say,  is  the  aim  of  them  all;  but  though  they  are 
perfectly  agreed  in  their  intention,  yet  they  are  not  so  with  regard 
to  the  instrument  which  they  use,  some  still  continuing  the  actual 
cautery,  others  using  other  different  instruments. 

The  ancients  preferred  the  cautery,  for  reasons  which  have 
already  been  assigned;  but  since  the  symptoms  of  callosity  and 
caries  have  been  found  to  be  very  infrequent,  and  the  os  unguis  has 
been  perforated  solely  with  a  view  to  make  an  artificial  passage 
into  the  nose,  the  cautery  has  with  many  lost  much  of  its  ancient 
credit,  and  other  instruments  have  been  substituted  in  its  place, 
which  give  less  pain  at  the  time  of  using,  and  leave  less  deformity 
afterward. 

But  though  many  have  laid  aside  the  hot  iron,  yet  it  still  has 
its  advocates,  who  prefer  it  to  every  other  instrument,  and  who 
have  therefore  endeavoured  to  obviate  its  inconveniences:  they 
have  directed  that  the  cannula  through  which  it  passes  be  made  of 
a  conical  form,  and  so  large  at  its  lower  end,  as  that  they  shall  not 
touch  each  other;  they  have  ordered  this  cannula  to  be  wrapped 
round  with  wet  rag,  at  the  time  of  using  it;  they  have  placed  a 
check  upon  the  top  of  the  iron  to  prevent  its  point  from  going  too 
far,  and  have  been  particular  in  directing  us  to  withdraw  it  as  soon 
as  it  is  got  through. 

But  notwithstanding  these  and  every  other  caution,  the  cautery 
gives  great  pain  at  the  time  of  using;  it  lengthens  the  attendance, 
and  most  commonly  produces  unnecessary  deformity  even  in  the 
hands  of  the  most  dexterous;  not  to  mention  the  horror  occasioned 
by  thrusting  a  hot  iron  into  the  corner  of  the  eye. 

When  the  inconveniences  arising  from  the  use  of  this  instru- 

"  corrupUone,  sola  siqu'irlem  ejus  superficie  corrupta  aut  altera  sat  fuerit 
**" partem  laesam  abradere."  Petr.  de  Marchktti. 

And  Mr.  Verduc,  a  very  modern  writer,  is  also  of  the  same  opinion,  "Le 
"  mellleur  remede  pour  amorter  I'acide  qui  cause  la  carie,  c'est  de  pass^p 
"  legerement  un  cautre  actuel  sur  I'os  sans  le  percer." 
VOL.  I.  D  d 


210  OBSERVATIONS  ON  THE 

ment,  even  in  the  best  hands,  are  important,  it  may  be  easily  guess- 
ed what  tlie)  must  be  in  those  of  the  clumsy  and  ignorant;  and 
therefore,  unless  some  real  advantage  attends  it,  it  ought  certainly 
to  be  so  discouraged,  that  no  one  may  attempt  to  revive  it.  Let 
us  then  see  with  what  intent  it  has  been  used  by  those  who  have 
appeared  most  fond  of  it,  and  who  may  fairly  be  supposed  to  have 
best  known  how  to  manage  it. 

The  defence  made  by  the  wet  rag  against  the  heat  of  the  iron, 
the  disproportioned  size,  and  the  figure  of  the  cannula,  very  plainly 
show,  that  its  effect  is  designed  to  be  executed  by  the  point  only; 
and  the  check  at  the  upper  end  as  clearly  sliows,  that  that  point  is 
designed  to  pass  no  farther  than  just  through  the  bone,  while  all  the 
ill  effects  are  occasioned  by  the  upper  part  of  the  cautery  on  the 
eye-lids  and  angle  of  the  eye.  Now,  if  it  be  not  designed  to  pro- 
duce any  effect  on  any  of  the  parts  through  which  it  passes  down 
to  the  bone,  but  merely  to  burn  through  that  and  the  membrana 
narium,  and  thereby  make  an  opening  into  the  nose,  I  do  not  see 
how  it  differs  from  any  other  perforator  of  equal  size,  except  in 
the  mischief  it  does  to  the  parts  above,  which  it  should  not  affect. 

It  does  indeed  burn  the  bone  and  membrane,  through  which  it 
pierces,  and  thereby  prevents  the  orifice  from  closing  again  imme- 
diately; and  this  is  certainly  the  principal  end  of  perforation,  by 
whatever  instrument  it  is  performed;  but  it  is  also  as  certain,  that 
the  same  end  is  obtainable  by  means  less  mischievous  and  less 
horrible. 

Our  ancestors  had  a  very  plausible  reason  for  using  it:  their 
ideas  of  callosity  and  caries  always  accompanied  this  disease,  and 
authorised  them  to  make  use  of  such  applications  as  they  thought 
most  proper  in  such  cases:  but  now,  when  we  know  that  these  are 
symptoms  which  very  rarely  occur,  or  even  if  they  do,  that  they 
are  removeable  in  a  much  easier  manner,  we  are  no  longer  vindi- 
cated in  continuing  an  alarming  and  a  painful  process,  when  we 
can  obtain  the  same  end  by  much  gentler  means;  for  whether  the 
membrana  narium  be  burnt  through,  or  divided  in  any  other  man- 
ner, it  is  the  future  method  of  dressing  that  opening  that  must 
maintain  it,  let  it  be  made  by  whatever  instrument,  or  in  whatever 
manner  it  may. 

The  late  Mr.  Chesselden  was  a  warm  patron  of  the  cautery,  took 


FISTULA  LACHRYMALIS.  211 

a  great  deal  of  pains  to  prevent  it  from  doing  mischief,  and  has 
said  in  its  defence,  that — "  other  methods  of  curing  this  disease 
"have  been  much  recommended,  though  often  unsuccessful;  but 
"this,  well  performed,  is  infallible."  After  so  positive  an  asser- 
tion, I  am  sorrj  to  be  obliged  to  say  that  it  is  contradicted  by 
manifold  experience;  that  there  have  been  many  instances  of  per- 
fect cures  performed  without  the  use  of  a  cautery;  and  that  some 
of  those  who  have  been  cauterised  by  Mr.  Cheselden  himself,  have 
been  disappointed  in  the  expectation  of  one:  nor  could  he,  with 
all  the  pains  he  took,  prevent  the  effect  of  the  heat  of  the  iron,  or 
leave  his  patient  without  a  weeping  eye. 

The  intention  is  merely  to  make  an  opening  through  the  os 
unguis  and  membrana  narium  into  the  cavity  of  the  nose,  and  to 
treat  that  perforation  in  such  a  manner  as  that  it  shall  most  pro- 
bably remain  open,  and  give  passage  to  the  lachrymal  fluid  from 
the  puncta,  after  the  external  sore  is  healed. 

The  extreme  thinness  of  the  bone  renders  the  passage  of  the 
instrument  very  easy,  and  if  the  breach  which  is  made  be  of  any 
tolerable  size,  I  am  inclined  to  think  that  it  never  is  filled  up  again 
by  bone;  but  that  when  it  is  closed,  it  is  by  the  membrane;  and 
therefore  it  is  the  surgeon's  business  to  make  a  pretty  large  open- 
ing in  the  bone,  and  to  prevent  its  being  closed  again,  by  render- 
ing the  edges  of  the  membrane  on  each  side  of  it  callous. 

To  make  this  opening,  many  different  instruments  have  been 
devised  and  used;  a  large  strong  probe,  an  instrument  like  a  com- 
mon gimlet,  a  curved  trocar,  &c.  &c.  each  of  which,  if  dex- 
terously and  properly  applied,  will  do  the  business  very  well;  the 
one  necessary  caution  is,  so  to  apply  whatever  instrument  is  used, 
that  it  may  pierce  through  that  part  of  the  bone  which  lies  imme- 
diately behind  the  sacculus  lachrymalis,  and  not  to  push  up  too 
far  into  the  nose,  for  fear  of  injuring  the  os  spongiosum  behind, 
while  it  breaks  its  way. 

For  my  own  part,  I  have  always  used  the  curved  trocar,  which 
has  served  my  purpose  well,  and  from  which  I  have  never  expe- 
rienced any  inconvenience:  in  using  it  the  point  should  be  turned 
obliquely  downward,  from  the  angle  of  the  eye  toward  the  inside 
of  the  nose;  the  accomplishment  of  the  breach  will  be  known  by 
the  discharge  of  blood  from  the  nostril,  and  of  air  from  the  woun-d 


312  OBSERVATIONS  ON  THE 

upon  blowing  the  nose.  The  most  precise  direction  in  this  part 
of  ihe  operation  will  be  of  but  little  use  to  him  who  has  no  idea 
of  the  natural  structure  and  disposition  of  the  parts  concerned,  and 
who  ought  therefore  to  get  such  information  as  soon  as  he  can: 
but  whoever  is  at  all  acquainted  with  this  matter,  or  will  attend 
to  the  situation  and  connexion  of  the  os  unguis,  knows  that  this 
bone  is  divided  into  two  parts  by  a  perpendicular  ridge;  that  the 
lachrvmal  sac  is  connected  to  all  thai  part  which  is  anterior  to 
this  ridge;  and  that  the  posterior  part  of  the  bone  contributes  to 
form  the  orbit  of  the  eye,  and  has  little  or  no  connexion  with  the 
lachrymal  sac:  the  trocar  must  be  applied  therefore  to  that  part  of 
the  bone  which  is  anterior  to  the  ridge,  and  consequently  behind 
the  lachrymal  bag.  By  the  passage  of  the  instrument,  all  this  part 
of  the  bone  will  in  all  probability  be  broken,  but  from  which  no 
mischief  will  ensue. 

An  attention  to  the  natural  situation  of  these  parts  will  also  show 
the  practitioner,  that  if  the  point  of  his  instrument  be  passed  in  a 
transverse  direction  with  regard  to  the  nose,  the  os  spongiosum 
superius  will  be  unnecessarily  wounded  or  broken;  and  if  it  goes 
in  too  perpendicular  a  direction,  it  may  get  into  the  channel  of 
the  natural  duct,  and  its  point  will  be  stopped  by  bearing  against 
that  part  of  the  maxilla  superior  which  contributes  to  the  forma- 
tion of  that  channel. 

It  has  been  objected  to  the  trocar,  that  it  may  break  the  os 
unguis  to  some  distance  from  the  place  where  its  immediate  point 
is  fixed:  to  which  I  can  only  answer,  that  I  have  performed  the 
operation  a  great  number  of  times,  and  never  yet  have  seen  any 
inconvenience  to  arise  from  it:  indeed,  a  total  removal  of  a  small 
piece  of  the  bone  would  be  a  thing  rather  to  be  wished  for  than 
avoided.  If  we  may  reason  by  analogy,  it  seems  to  be  a  necessary 
requisite  toward  preserving  a  future  passage;  for  we  very  well 
know,  in  a  caries  of  the  bones  forming  the  roof  of  the  mouth,  that 
they  are  sometimes  bare  for  a  large  compass,  and  by  casting  off 
leave  a  considerable  aperture  into  the  nose;  yet  in  many  cases, 
when  the  virus  is  removed,  and  the  habit  recruited,  that  opening 
will  so  contract  as  not  to  suffer  a  small  quill  to  pass  where  you 
might  have  introduced  your  finger,  nay  often  will  quite  close; 
and  therefore,  though  the  opening  made  in  the  os  unguis  may 


FISTULA  LACHRYMALIS.  213 

possibly  in  spite  of  all  endeavours  be  again  closed  up,  yet  a  free 
breach  in  it  seems  lo  be  the  most  likely  means  to  prevent  it;  and 
upon  this  principle  I  have  always  turned  the  perforator  round 
very  freely  whenever  I  have  used  it;  have  never  seen  any  mis-t 
chief  from  it;  and  do  attribute  the  success  I  have  had  with  it,  ia 
some  measure,  to  this  method  of  using  it. 

As  soon  as  the  perforation  is  made,  a  tent  of  lint  should  be 
introduced,  of  such  size  as  to  fill  the  aperture,  and  so  long  as  to 
pass  through  it  into  the  cavity  of  the  nose:  this  should  be  permit- 
ted to  remain  in  two,  three,  or  four  days,  till  the  suppuration  of 
the  parts  renders  its  extraction  easy;  and  after  that  a  fresh  one 
should  be  passed  every  day,  until  the  clean  granulating  appearance 
of  the  sore  makes  it  probable  that  the  edges  of  the  divided  mem- 
brane are  in  the  same  state.  The  business  now  is  to  prevent  the 
incarnation  from  closing  the  orifice,  for  which  purpose  the  end  of 
the  tent  may  be  moistened  with  spir.  vitriol,  ten.;  or  a  piece  of 
lunar  caustic  so  included  in  a  quill,  as  to  leave  little  more  than 
the  extremity  naked,  may  at  each  dressing,  or  every  other,  or 
every  third  day,  be  introduced;  by  which  the  granulation  will  be 
repressed,  and  the  opening  maintained:  and  when  this  has  been 
done  for  some  little  time,  a  piece  of  bougie  of  proper  size,  or  a 
leaden  cannula,  may  be  introduced  instead  of  the  tent,  and  leaving 
off  all  other  dressing,  the  sore  may  be  suffered  to  contract  as  much 
as  the  bougie  will  permit,  which  should  be  of  such  length,  that  one 
extremity  of  it  may  lie  level  with  the  skin  in  the  corner  of  the 
eye,  and  the  other  be  within  the  nose. 

The  longer  time  the  patient  can  be  prevailed  upon  to  wear  the 
lS)Ougie,  the  reore  likely  will  be  the  continuance  of  the  opening; 
and  when  it  is  withdrawn,  the  external  orifice  should  be  covered 
only  by  a  superficial  pledget  or  plaster,  and  suffered  to  heal  under 
moderate  pressure. 

There  is  another  method  which  has  been  much  recommended 
by  some  French  writers  to  prevent  the  closing  of  the  opening  in 
the  OS  unguis:  which  is,  to  introduce  a  cannula  either  of  gold  or 
silver,  or  lead,  into  the  aperture,  and  to  permit  the  sore  to  heal 
over  it,  suffering  the  cannula  to  remain,  or  to  come  away  by  the 
nose. 


214  •  OBSERVATIONS  ON  THE,  StC. 

For  my  own  part,  I  cannot  say  any  thing  to  it,  having  never 
had  occasion  to  try  it;  the  cases  of  this  kind  which  I  have  had 
under  my  direction,  having  generally  succeeded  under  some  of  the 
methods  already  mentioned;  which  methods  will  frequently  prove 
successful,  if  the  surgeon  is  clear  in  his  attention,  pursues  it 
steadily  and  properly,  and  refrains  from  doing  too  much;  fhough  I 
must  again  repeat  what  I  have  said  before,  viz.  that  there  is  no 
method  of  treating  this  disorder  which  is  infallible,  none  that  will 
absolutely  and  in  all  cases  prevent  a  return,  especially  in  scrophu- 
lous  habits;  yet,  when  a  just  distinction  is  made  between  those 
cases  which  are  in  their  own  nature  incapable  of  cure,  and  those 
which  by  being  improperly  treated  are  not  cured,  I  am  inclined 
to  believe,  that  the  number  of  the  former  will  be  found  much 
smaller  than  it  is  generally  imagined.' 

■  It  must  appear  to  whoever  has  perused  the  foregoing  tract,  that  the  author 
took  great  pains  and  bestowed  much  attention  on  it.  His  accurate  descrip- 
tion of  the  disease  rescued  it  from  the  obscurity  with  which  it  had  been 
enveloped;  and  the  method  of  cure  which  Mr.  Pott  proposed,  was  a  great 
improvement  on  the  awkward,  painful,  and  destructive  operations  which 
had  been  practised  by  Mr.  Chesselden,  and  others  of  his  predecessois. 

But  I  must  confess  that  I  never  was  perfectly  satisfied  with  it:  I  attended 
many  of  these  cases  with  Mr.  Pott,  and  in  several  the  artificial  passage 
through  the  os  unguis  became  obliterated  soon  after  the  bougie  was  left 
off,  though  it  had  been  worn  a  considerable  time  ;  in  consequence  of  which 
sometimes  a  fresh  collection  of  mucus  was  formed,  producing  inflammation 
and  suppuration.  In  others,  where  no  great  inflammation  ensued,  the 
tears,  not  finding  a  passage,  again  took  their  course  down  the  cheek.  It  was, 
however,  as  before  observed,  a  great  amendment  on  the  operations  which 
had  preceded,  and  has  laid  the  foundation  of  the  improvements  which  have 
taken  place  since  the  time  when  it  was  written. 

The  introduction  of  metallic  tubes,  which  have  been  since  recommended 
by  other  writers,  have  also  been  found  inadequate  to  the  purpose,  as  either 
from  the  tubes  shifting  their  position,  or  from  their  being  filled  with  inspis- 
sated mucus,  the  tears  were  prevented  from  passing. 

The  nail-headed  style  which  Mr.  Ware  has  recommended  in  his  valua- 
ble work  on  the  fistula  lachrymalis  must  be  allowed  to  be  a  great  improve- 
ment, and  in  my  opinion  the  best  method  of  treating  the  complaint.  The 
opening  for  the  introduction  of  the  style  is  small.  The  style  acts  as  a  capil- 
lary tube,  by  attraction,  and  readily  conducts  the  tears  into  the  nose — it  may 
be  taken  out  as  often  as  it  may  be  necessary  to  clean  it,  and  the  duct  may  be 
washed  by  a  syringe — the  style  may  be  worn  as  long  as  may  bethought  neces- 
sary, as  it  creates  little  disfigurement,  appearing  only  as  a  small  black 
patch.    E. 


SOl^E  FEW 

GENERAL  REMARKS 

ON 

FRACTURES  AND  DISLOCATIONS. 


ON 


FRACTURES  AND  DISLOCATIONS. 


No  part  of  surgery  is  thought  to  be  so  easy  to  understand,  as 
that  which  relates  to  fractures  and  dislocations.  Every  the  most 
inexpert  and  least  instructed  practitioner,  deems  himself  perfectly 
qualified  to  fulfil  this  part  of  the  chirurgic  art;  and  the  majority 
even  of  these  are  affronted  by  an  offer  of  instruction,  on  a  subject 
with  which  they  think  themselves  already  so  well  acquainted. 

Tl^is  is  also  the  opinion  of  a  considerable  part  of  the  people. 
They  regard  bone-setting  (as  it  is  called)  as  no  matter  of  science; 
as  a  thing  which  the  most  ignorant  farrier  may,  with  the  utmost 
ease,  become  soon  and  perfectly  master  of;  nay,  that  he  may  re- 
ceive it  from  his  father  and  family  as  a  kind  of  heritage.  We  all 
remember  the  great,  though  short-lived  reputation,  of  the  late  Mrs. 
Mapp.  We  all  remember,  that  even  the  absurdity  and  imprac- 
ticability of  her  own  promises  and  engagements  were  by  no  means 
equal  to  the  expectations  and  credulity  of  those  who  ran  after  her; 
that  is,  of  all  ranks  and  degrees  of  people,  from  the  lowest  labourer 
or  mechanic,  up  to  those  of  the  most  exalted  rank  and  station; 
several  of  whom  not  only  did  not  hesitate  to  believe  implicitly  the 
most  extravagant  assertions  of  an  ignorant,  illiberal  woman;  but 
even  solicited  her  company;  and,  at  least,  seemed  to  be  pleased 
with  her  conversation. 

The  desire  of  health  and  ease,  like  that  of  money,  seems  to  put 
all  understandings',  and  all  men,  upon  a  level;  the  avaricious  are 
duped  by  every  bubble;  the  lame  and  the  unhealthy  by  every 
quack.  Each  party  resigns  his  understanding;  swallows  greedily, 
and  for  a  time  believes  implicitly,  the  most  groundtess,  ill-founded, 

VOL.  r.  E  e 


218  REMARKS  ON  FRACTURES 

and  delusory  promises;  and  nothing  but  loss  and  disappoint- 
ment ever  produce  conviction.  Arts,  trades,  and  manufactures, 
are  allowed  to  be  learnt,  in  general,  by  those  who  have  employed 
a  proper  quantity  of  time  and  attention  in  such  pursuits;  and  it 
seems  most  singularly  unjust,  as  well  as  untrue,  to  suppose  that 
medical  people  are  the  only  part  of  mankind  who  are  all  either  so 
dull  as  not  to  be  able  to  learn;  or  so  profligately  wicked,  as  not  to 
practise  their  art  to  the  best  of  their  judgment,  and  to  the  greatest 
possible  advantage  to  mankind.  Surely  there  are,  and  always 
have  been  among  us,  as  well  as  in  all  other  classes,  men  truly  able 
and  perfectly  honest;  men,  who  well  understand  the  science  which 
tliey  profess;  and  who  practise  it  not  only  with  great  ability,  but 
with  strict  integrity.  I  cannot  be  supposed  to  say  or  to  mean  this 
as  a  vindication  of  every  individual.  Different  men  have  different 
powers  and  capacities.  The  multitude  with  us,  as  with  all  ranks 
and  degrees,  (not  excepting  any,)  will  always  be  deficient.  Ad- 
vancements in  knowledge  will  always  be  owing  to  the  ingenuity 
and  industry  of  a  few  particular  people;  but  such  advancements 
will  always,  in  due  time,  more  or  less  influence  the  rest.  They 
have  so  done;  and  notwithstanding  that  there  remains  a  great 
deal  yet  to  be  done,  to  bring  surgery  to  that  degree  of  perfection 
of  which  it  is  capable,  yet  whoever  will  compare  the  present  prac- 
tice of  it  with  that  of  a  very  few  years  ago,  cannot  justly,  or  with 
any  decree  of  candour,  withhold  his  commendation  from  his  con- 
temporaries. 

I  remember,  some  years  ago,  to  have  heard  a  judge  from  the 
bench  tell  a  jury,  th.it  he  believed  a  country  bone-setter  knew  full 
as  much,  if  not  more  of  the  matter  of  his  own  business,  tlian  any, 
the  most  eminent  surgeon  in  the  kingdom.  I  will  not  enter  into 
a  disquisition  concerning  the  validity  of  a  judge's  opinion.  Perhaps 
his  lordship  might  very  little  understand  the  thing  concerning 
which  he  decided  so  peremptorily:  without  either  injustice  or 
partiality,  I  may  certainly  suppose  him  to  have  been  a  much  more 
able  lawyer  than  surgeon;  and  I  believe  it  will  also  be  allowed, 
that  general  reflexions  of  this  kind  are,  and  must  be,  the  conse- 
quences of  a  petulant  attempt  to  be  witty,  rather  than  of  convic- 
tion; and  therefore,  at  best,  are  frivolous  and  idle.  But,  on  the 
other  hand,  I  am  very  willing  to  allow  (what  indeed  I  have  already 


AND  DISLOCATIONS. 


S19 


allowed)  that  many  parts  of  surgery  are  still  capable  of  consider- 
able improvement;  and  this  part,  perhaps,  as  much  as,  if  not 
more  than,  any;  it  being  one  of  those  in  which  a  general  observ- 
ance of,  and  rigid  adherence  to,  old  prescribed  rules,  have  pre- 
vented the  majority  of  practitioners  from  venturing  to  think  for 
themselves;  and  have  induced  them  to  go  on  in  a  beaten  track, 
from  which  they  might  not  only  safely,  but  advantageously 
deviate. 

The  general  doctrine,  relative  to  fractures,  is  contained  under 
tlie  following  heads,  as  parts  of  the  treatment  of  them: 

Extension. 
Counter-extension. 
Coaptation,  or  setting, 
Applicaiion  of  medicaments. 
Deligation,  or  bandage. 
Position. 
•  Prevention,  or  relief  of  accidents. 

This  is  the  general  arrangement  of  the  subject  by  most  of  the 
writers  on  it,  and  a  very  just  and  proper  one  it  is;  but  notwith- 
standing the  parade  of  books  under  these  various  heads,  much  less 
alteration  will  be  met  with,  since  the  times  of  Hippocrates,  Galen, 
and  Celsus,  than  an  inquirer  might  expect,  or  than  the  subject  is 
capable  of. 

I  must  desire  that  what  I  have  said  may  not  be  misconstrued. 
I  do  not  mean  that  there  are  not,  and  have  not  at  all  times,  been 
men  of  particular  ingenuity,  who  have  deviated  from  the  common 
methods,  and  have  greatly  improved  the  art;  but  still  the  com- 
mon methods  are  the  same,  and  the  multitude  of  practitioners  re- 
ligiously follow  them.  Let  me  not  therefore  be  charged  with  pre- 
sumption or  arrogance,  if  I  say,  that  under  almost  every  of  the 
foregoing  heads  the  practice  is  capable  of  considerable  improve- 
inents — improvements,  which  would  show  rationality  and  sense 
in  the  surgeon,  and  produce  ease  and  convenience  to  the  patient. 

I  am  aware  that  some  of  my  readers  may  be  inclined  to  charge 
me  with  affecting  to  deviate  from  the  commonly  prescribed  rules; 


220  REMARKS  ON  FRACTURES 

and  to  contradict  opinions,  which  a  great  length  of  time,  and  a 
Ipng  successsion  of  writers  have  given  sanction  to. 


"  Imberbes  dkUcere,  senes  perdenda  fateri ;" 

is  a  hard  lesson  sometimes  to  human  vanity,  and  what  requires 
some  degree  of  candour  to  learn.  But,  on  the  other  hand,  if  it 
was  not  now  and  then  practised,  I  know  not  how  such  an  art  as 
surgery  (whose  basis  is  experience)  could  ever  be  improved.  Our 
ancestors  deserve  our  best  thanks  for  the  assistance  which  they 
have  given  us:  where  we  find  them  to  be  right,  we  are  obliged  to 
embrace  their  opinions  as  truths;  but  implicit  faith  is  not  required 
from  man  to  man;  and  our  reverence  for  our  predecessors  must 
not  prevent  us  from  using  our  own  judgments.  Ancient  and  mo- 
dern are  mere  sounds,  and  can  signify  nothing  in  this  case,  un- 
less with  the  former  we  can  connect  an  idea  of  truth  established 
and  confirmed  by  time  and  experience,  and  with  the  latter,  that 
of  demonstrable  improvement  upon  what  has  gone  before^ 

If  what  I  have  to  urge  is  not  capable  of  being  verified  and  con- 
firmed by  experience,  it  must  sink  into  nothing;  but  if,  upon  trial, 
it  shall  be  found  by  the  majority  (as  it  has  been  by  me  and  some 
otlrers)  to  be  not  only  true  and  practicable,  but  highly  conducive 
to  the  ease  and  benefit  of  the  aiflicted,  it  ought  to  have  as  much 
weight,  though  delivered  by  a  living  writer,  as  if  it  had  proceed- 
ed from  the  remotest  antiquity:  its  use,  not  its  date,  should  give 
it  value.  If  practitioners,  since  the  time  of  Albucasis,  had  been 
contented  with  his  doctrine,  and  never  had  ventured  to  think  for 
themselves,  surgery  had  not  been  what  it  now  is,  and  its  great 
merit  would  still  have  consisted  in  the  multiplicity  of  its  hot 
irons.  In  short,  to  such  as  think  that  we  are  seldom  or  never  to 
deviate  from  the  opinions  and  practice  of  those  who  have  gone 
before  us,  I  shall  take  the  liberty  of  answering  in  the  words  of 
the  great  Mr.  Locke,  who  says,  "  The  floating  of  other  men'» 
"  opinions  in  our  brains,  makes  us  not  one  jot  the  more  know- 
"  ing,  though  they  happen  to  be  true.  And  beaten  tracks  lead 
"  those  whose  thoughts  reach  only  to  imitation,"  '  Non  quo  eun- 
'  dem  est,  sed  quo  itur.' 


AND  DISLOCATIONS.  221 

Before  I  enter  on  the  subject,  the  reader  will  give  me  leave  to 
acquaint  him,  that  it  is  by  no  means  my  intention  to  write  a  re- 
gular treatise  on  fractures,  although  I  think  the  subject  well  de- 
serving of,  and  even  requiring  one.  I  only  mean  to  throw  out  a 
few  hints,  which  I  hope  may  prove  intelligible  and  useful. 

The  first  article,  in  the  general  arrangement,  is  extension;  un- 
der which  may  also  be  comprehended  the  second,  or  counter- 
extension. 

In  order  to  accomplish  this,  we  are  directed,  if  the  fracture  be 
of  the  thigh  or  leg,  to  place  the  patient  in  a  supine  posture,  and 
the  broken  limb  in  a  strctight  one;  then,  having  the  upper  part  of 
it  held  firm  and  steady,  by  proper  assistants,  we  are  ordered,  by 
means  of  hands,  ligatures,  lacs,  or  even  in  some  cases  by  pieces 
of  machinery,  to  make  such  an  extension  or  stretching  of  the 
limb  lengthways,  as  shall  enable  the  surgeon  to  place  the  ends  of 
the  broken  bone  in  as  apt,  that  is,  in  as  even  a  position,  with  regard 
to  each  other,  as  the  nature  of  the  fracture  will  admit.  This  is 
a  short  description  .of  what,  in  the  vulgar  phrase,  is  called  setting 
a  broken  bone;  and  is  most  commonly  a  painful  operation  to  the 
patient,  a  fatiguing  one  to  the  operator  and  his  assistants;  and 
what  is  worse,  is,  in  many  instances,  found  to  be  inefficacious;  at 
least,  not  fully  to  answer  the  intention  of  the  one,  or  the  expecta- 
tion of  the  other.* 

Writers  in  general  are  very  precise  and  formal  in  the  direc- 
tions which  they  have  given  for  the  due  and  proper  accomplish- 

»  "  Instruments  for  extension  are  threefold  ;  first,  the  surgeon's  hands,  &c. ; 
"  secondly,  fuues  and  habenae,  a  sort  of  bandage  fit  to  pluck  at,  in  order  for 
"  extension ;  thirdly,  there  are  organa  and  machinenaata,  engines  used  by  us, 
"  and  invented  by  the  ancients," 

WiSEMAIf. 

The  very  mention  of  funes,  haben«,  organa,  and  machinemata,  implies  a 
force  exceeding  that  of  mere  hands;  a  degree  of  force,  which  in  a  fracture 
never  can  be  wanted  if  the  limb  be  I'ightly  placed ;  a  degree  of  force  which 
must,  in  the  nature  of  things,  do  mischief;  and  a  degree  of  force,  whose 
whole  effect,  however  great,  must  cease  immediately  upon  its  being  remov- 
ed; unless  the  fracture  be  particularly  and  luckily  circumstanced. 

There  are  not  wanting  instances  of  the  muscles  surrounding  a  bad  though 
simple  fracture,  having  been  torn  by  extension ;  and  spasm  and  other  mis- 
chief thereby  produced.  See  cautions  on  this  subject,  laid  down  by  many 
old  writers,  particularly  by  Galen  and  Albucasis. 


223  REMARKS  ON  FRACTURES 

ment  of  this  purpose.   They  have  toltl  us,  that  the  extension  should 
be  made  slowly  and  gradually;  and  should  be  continued  till  ihe 
ends  of  the  bone  are  separated  from  each  other  sufficiently  to  ad- 
mit of  the  fracture  being  set  without  risk  of  breaking  off  any 
points  or  inequalities,  and  to  enable  us  to  place  them  perfectly 
smooth  and  even.     All  this,  like  many  other  of  the  preceptive 
parts  of  physic  and  surgery,  is  very  pretty  on  paper,  but  not  often 
found  to  be  practicable  in  the  chamber.     The  direction  to  con- 
tinue the  extension  until  the  ends  of  the  bones  are  at  a  certain 
distance,  lengthways  from  each  other,  plainly  implies  a  consider- 
able degree  of  violence;  the  limb  must  by  such  force  be  not  only 
made  longer  than  its  fellow,  or  than  nature  ever  intended  it 
should  be,  but  this  procrustian  method  of  lengthening  it  is  ordered 
to  be  executed  while  the  limb  is  in  such  position  as  to  put  all  the 
muscles  most  on  the  stretch,  and  render  them  least  likely  to  yield 
to  it.   Now,  not  to  say  a  word  of  the  great  probability  of  the  points 
and  edges  of  the  fracture  wounding  the  surrounding  muscles,  or  of 
such  wounds  being  more  painful,  or  worse  in  their  consequences, 
when  inflicted  on  parts  thus  stretched,  or  of  the  addition  that 
such  force  must  make  to  the  laceration  already  necessarily  made 
by  the  fracture;  I  say,  not  to  mention  a  word  of  all  this,  can  the 
method  itself  (without  considering  any  accidental,  adjunct  cir- 
cumstances) be  practised  in  every  fracture,  or  even  in  the  majori- 
ty of  fractures.?  Will  it  be  done  properly  by  the  rude,  the  inatten- 
tive, and  the  ignorant?  If  attempted  by  such,  will  it  not  be,  is  it 
not,  frequently  productive  of  pain,  tumefaction,  inflammation,  and 
extravasation;  which  are  set  to  the  account  of  the  nature  of  the 
fracture,  and  to  inevitable  necessity?  and  when  done  ever  so  pro- 
perly, will  it,  can  it,  in  an  oblique  or  splintered  fracture,  answer 
the  purpose  it  is  intended  for,  or  produce  a  more  happy  coaptation? 

Whence  arise  these  evils  ?  from  whence  proceed  the  difficulty 
and  the  so  frequent  disappointment? 

In  order  to  understand  this  rightly,  let  us  for  a  moment  con- 
sider, what  is  or  ought  to  be  meant  by  the  terms  extension  and 
counter-extension,  and  why  they  become  necessary:  for  if  the 
greater  part  of  the  pain  attending  such  method,  and  the  frequency 
of  disappointment,  both  to  patient  and  surgeon,  should  be  found 
to  arise  from  this  part  of  the  process;  and  that  such  part  can  be 


AND  DISLOCATIONS.  223 

either  disused  without  prejudice;  or  altered  with  advantage,  we 
oughl  to  think  ourselves  hoppy  in  having  it  in  our  power  to  correct 
our  error. 

Neither  extension,  nor  counter-extension,  can  ever  be  neces- 
sary, on  account  of  the  mere  fracture,  considered  abstractedly. 
The  broken  ends  of  the  bone  or  bones  are  of  themselves  inactive; 
and,  if  not  acted  upon  by  other  parts,  they  would  always  remain 
motionless.  When  any  attempt  is  made  to  put  them  into  motion, 
they  of  themselves  can  make  no  possible  resistance;  nor  can  any 
be  made  on  their  part,  save  an  accidental  one  arising  from  the  points 
of  the  fracture  being  entangled  with  each  other;  and  when  they 
have  been  once,  by  the  hand  of  the  surgeon,  placed  properly  and 
evenly  with  regard  to  each  other,  they  would  of  themselves  for 
ever  remain  so.  What  then  is  the  reason  why  fractured  bones 
always  suffer  a  greater  or  a  less  degree  of  displacement?  why  is  a 
broken  limb  almost  always  shorter  than  its  fellow?  what  creates  the 
resistance  which  we  always  find  in  attempting  to  bring  the  fractured 
parts  aptly  together?  whence  does  it  proceed,  that  when  we  have 
done  all  that  is  in  our  power,  (according  to  this  mode  of  acting,)  the 
ends  of  the  fracture  will,  in  many  cases,  become  again  displaced, 
and  lameness  and  deformity  frequently  ensue?  In  short,  what  are 
the  parts  or  powers  which  act  on  the  bones,  and  which,  by  so 
acting  on  them,  produce  all  these  consequences  ? 

These  parts  are  the  muscles,  the  only  moving  powers  in  the 
animal  body.  By  the  action  of  these  on  the  bones,  all  locomotion 
is  performed,  and  cannot  be  performed  without  them;  and  although 
all  bones,  when  broken,  are  in  some  degree  displaced  and  short- 
ened, yet  it  will  always  be  found,  that  in  proportion  as  the  mus- 
cles surrounding,  or  in  connexion  with  a  bone,  are  strong  or  nu- 
merous, or  put  into  action  by  inadvertence  or  spasm,  so  will  the 
displacement  of  the  ends  of  such  bone,  when  fractured,  be.  The 
even  and  smooth  position  of  the  fractured  ends  of  a  tibia,  when 
the  fibula  of  the  same  leg  is  entire  and  unhurt;  that  is,  when  the 
muscles  therefore  cannot  act  upon  the  former;  the  visible  and  im- 
mediate deformity,  when  both  the  before  mentioned  bones  are 
broken  nearly  in  the  same  place;  that  is,  when  the  muscles  can 
act  upon,  and  displace  such  fracture;  the  great  difficulty  fre- 
quently met  with,  in  endeavouring  to  get  a  broken  os  femoris  to 


224:  REMARKS    ON    FRACTURES 

lie  even  tolerably  smooth,  and  to  prevent  such  broken  Hmb  from 
being  much  shorter  than  the  other,  are,  among  others  vi'hich  might 
be  produced,  such  strong,  and  irrefragable  proofs,  as  need  no 
comment. 

From  the  muscles  then,  and  from  them  only,  proceeds  all  the 
difficulty  which  we  meet  with  in  making  our  extension;  and  by 
the  resistance  of  these,  and  of  these  only,  are  we  prevented  from 
being  always  able  to  put  the  ends  of  a  fractured  bone  immediately 
into  the  most  apt  contact. 

Let  us  in  the  next  place  consider,  what  it  is  which  gives  to  a 
muscle,  or  to  the  principal  muscles  of  a  limb,  the  greatest  power 
of  resisting  any  force  applied  to  them  ab  externo,  in  order  to  draw 
them  out  into  greater  length;  for  whatever  that  is,  the  same  thing 
will  be  found  to  be  the  cause  of  the  different  degrees  of  resistance 
in  setting  a  fracture. 

Does  not  the  putting  the  muscles  in  a  state  of  tension,  or  into 
a  state  approaching  nearly  to  that  of  tension,  almost  necessarily 
produce  this  effect?  or,  in  other  words,  does  not  that  position  of  a 
limb,  which  puts  its  muscles  into,  or  nearly  into  such  a  state,  give 
such  muscles  an  opportunity  of  exerting  their  greatest  power 
either  of  action  or  of  resistance?  This  I  believe  cannot  be  denied. 
On  the  other  hand,  what  is  the  state  or  position  of  a  muscle  which 
is  most  likely  to  prevent  it  from  acting,  and  to  deprive  it  most  of 
its  power  of  resistance?  or  what  is  that  position  of  a  limb,  which, 
in  the  case  of  a  broken  bone,  will  most  incapacitate  the  muscles 
from  acting  on,  and  displacing  it;  and  in  the  greatest  degree  re- 
move that  resistance  which  they  have  it  in  their  power  to  make 
to  the  attempts  for  the  reduction  of  such  fracture?     Is  it  not 
obvious,  that  putting  a  limb  into  such  .'position  as  shall  relax  the 
whole  set  of  muscles  belonging  to  or  in  connexion  with  the  bro- 
ken bone,  must  best  answer  such  purpose?    Nothing  surely  can 
be  more  evident.     If  this  be  granted,  will  it  not,  must  ij.  not  fol- 
low, that  such  posture  of  a  broken  limb  must  be  the  best  for 
making  the  reduction;  that  is,  it  must  be  that  in  which  the  muscles 
will  resist  the  least,  and  be  least  likely  to  be  injured;  that  in 
which  the  broken  bone  will  be  most  easily  set,  the  patient  suffer 
least  pain  in  present,  and  that  from  which  future  lameness  and 
deformity  will  be  least  likely  to  happen.     A  little  attention  to 


AND  DISLOCATIONS.  22$ 

what  frequently  occurs,  may  perhaps  serve  to  illustrate  and  con- 
firm this  doctrine  better  than  mere  assertion. 

What  is  the  reason  why  no  man,  however  superficially  ac- 
quainted with  his  art,  ever  finds  much  trouble  in  setting  a  fractured 
OS  humeri,  and  that  with  very  little  pain,  and  a  very  small  degree 
of  extension?  Is  it  not  because  both  patient  and  surgeon  concur  in 
putting  the  arm  into  a  state  of  flexion;  that  is,  into  such  a  state  as 
relaxes  all  the  muscles  surrounding  the  broken  bone?  and  is  it  not 
for  the  same  reason  that  we  so  very  seldom  see  (comparatively 
speaking  of  this  bone  with  others)  a  deformity  in  consequence  of  a 
fracture  of  it?  Let  the  reduction  be  attempted  with  the  arm  ex- 
tended from  the  body,  and  the  difficulty  of  setting  will  be  much 
increased:  let  the  arm  be  deposited  in  an  extended  straight  position, 
and  the  fracture  will  be  displaced  and  lie  uneven. 

Apply  the  same  kind  of  reasoning  to  the  os  femoris;  that 
bone  whose  fracture  so  often  lames  the  patient  and  disgraces  the 
surgeon. 

Will  it  not  be  more  cogent,  and  more  conclusive,  in  proportion 
as  the  muscles  in  connexion  with  this  bone  are  more  numerous  and 
stronger? 

I  would  ask  any  man,  who  has  been  much  conversant  with 
accidents  of  this  kind,  what  is  the  posture  which  almost  every 
person  (whose  os  femoris  has  been  newly  broken)  puts  himself 
into  in  order  to  obtain  ease,  until  he  gets  proper  assistance?  Do 
such  people  stretch  out  their  limb,  and  place  their  leg  and  thigh 
straight,  and  resting  on  the  calf  and  heel?  I  believe  seldom  or 
never.  On  the  contrary,  do  not  such  people  almost  always  bend 
their  knee,  and  lay  the  broken  thigh  on  its  outside?  And  is  not 
the  reason,  why  this  must  be  the  most  easy  posture,  obvious? 

From  want  of  attention  to,  or  from  not  understanding  these  few 
self-evident  principles,  many  people  permit  their  patients  to  suffer 
considerable  inconvenience,  both  present  and  future. 

It  is  a  maxim  universally  taught  and  received,  that  a  fractured 
linVu  may  be  in  such  state,  as  not  to  admit  of  the  extension  neces- 
sary for  its  being  set;  that  is,  if  assistance  be  not  at  hand,  when 
the  accident  happens;  if  they  who  bring  the  patient  home,  do  it 
so  awkwardly  or  rudely  as  to  bruise  and  hurt  the  part;  if  from 
drunkenness,  folly,  or  obstinacy  in  the  patient,  it  happens  that  the 

VOL.  I.  j<  f 


226  KEMAKKS  ON  FRACTURES 

limb  is  so  disordered  that  it  is  found  to  be  much  swollen,  inflamed,  * 

and  paiafu!,  it  is  allowed  not  lo  be  in  a  state  to  admit  extension. 

This,  I  say,  is  a  general  maxim,  and  founded  upon  very  just 
principles;  but  what  is  the  general  practice  in  consequence  of  it? 
It  is,  to  place  the  limb  in  an  extended,  straight  position,  to  secure 
it  in  that,  and  then  by  proper  means,  such  as  fomentation,  poul- 
tice, &c.  to  endeavour  to  remove  the  tension  and  tumor.  Now,  if 
it  be  considered  that  the  swollen,  indurated,  and  inflamed  state  of 
the  muscles  is  the  circumstance  which  renders  extension  impro- 
per, surely  it  must  be  obvious,  that  such  position  of  the  limb  as 
necessarily  puts  these  very  muscles  in  some  degree  on  the  stretch, 
must  be  a  very  improper  one  for  the  accomplishment  of  what 
ought  to  be  aimed  at.  Under  this  method  of  treatment,  the  space 
of  time  which  passes  in  the  removal  of  the  tension,  is  sometimes 
considerable;  so  considerable  that  a  happy  and  an  even  coaptation 
becomes  afterwards  impracticable;  and  then  (his  accident,  which 
nine  times  in  ten  is  capabfe  of  immediate  relief,  is  urged  as  an  ex- 
cuse for  unnecessary  lameness  and  deformity. 

How  then  are  we  to  conduct  ourselves  in  such  circumstances.* 
The  nature  of  the  complaint  points  out  the  relief.  Extension  is 
wrong;  a  straight  position  of  the  thigh  or  leg  is  a  degree  of  exten- 
sion, and  a  still  greater  degree  of  it  in  proportion  as  the  muscles 
are  in  such  circumstances  as  to  be  less  capable  of  bearing  it. 
Change  of  posture  then  must  be  the  remedy,  or  rather  the  placing 
the  limb  in  such  manner  as  to  relax  all  its  muscles,  must  be  the 
most  obvious  and  certain  method  of  relieving  all  the  ills  arising 
from  a  tense  state  of  them;  which  change  of  posture  will  be  at- 
tended wi;h  another  circumstance  of  very  great  consequence; 
which  is,  that  the  bones  may  in  such  posture  be  immediately  set, 
and  not  one  moment's  time  be  thereby  lost;  a  circumstance  of 
great  advantage  indeed!  for,  whatever  may  be  the  popular  or  pre- 
vailing opinion,  it  is  demonstrably  true,  that  a  broken  bone  can- 
not be  too  soon  put  to  rights;  as  mnsi  appear  to  every  one  who 
will  for  a  moment  consider  the  necessary  state  of  the  muscles, 
tendons,  and  membranes  surrounding,  and  the  medullary  organs 
con  ained  within  a  large  bone  broken  and  unset;  that  is,  iyiiig  in 
an  uneven  irregular  manner.  Can  any  truth  be  more  clear,  ihan 
that  if  the  fracture,  tension,  and  tumefaction  be  such  that  the  mus- 


AND  DISLOCATIONS.  227 

cles  cannot  bear  to  be  stretched  out  in  the  manner  necessary  for 
setting  :he  broken  bone  without  causing  great  pain,  and  perhaps 
bringing  on  still  worse  symptoms,  the  more  the  px)sition  of  that 
limb  makes  its  muscles  approach  toward  a  state  of  tension,  tbe 
less  likely  it  must  be  that  such  symptoms  should  remit,  and  the 
longer  it  must  be  before  the  wished-for  alteration  can  happen;  and 
consequently,  that  while  the  accomplishment  of  such  purpose  is 
by  every  other  means  aimed  at,  the  position  of  the  limb  ought 
most  certainly  to  contribute  to,  and  not  to  counteract  it?  In  short, 
if  the  experiment  of  change  of  posture  be  fairly  and  properly 
made,  the  objections  to  immediate  reduction,  from  tension,  tumour, 
&c.  will  most  frequently  be  found  to  be  groundless;  and  the  frac- 
ture will  be  capable  of  being  put  to  rights,  as  well  at  first  as  at  any 
distance  of  time  afterward. ** 

Extension  having  been  made,  and  the  broken  ends  of  the  bone 
having  been  placed  as  smooth  and  as  even  as  the  nature  of  the 

''  Mr  Pott's  recommendation,  to  lose  no  time  before  a  broken  bon^  is  re- 
duced or  set,  ought  to  be  adopted  by  ever)'  practitioner  ;  and  I  earnestly  ad- 
vise, that  whoever  is  sent  for  to  a  fractured  bone,  should  never  leave  it  until 
he  has  set  it,  or  placed  it  in  the  best  possible  position.  I  have  often  heard 
surgeons  say  they  did  not  attempt  to  set  a  fracture  at  first,  because  there  was 
too  much  inflammation  ;  and  I  have,  in  such  cases,  found  the  limb  lying  on  a 
pillow,  without  even  the  support  of  a  splint,  or  at  best  with  a  splint  placed 
under  a  thick  pillow,  where  it  could  not  act;  as  if  splints  were  entirely  use- 
less until  the  fracture  was  perfectly  reduced.  Tliis  is  a  very  serious  error; 
for  supposing  the  bones  not  completely  set,  splints,  properly  applied,  must 
undoubtedly  give  some  stability,  and  tend,  in  some  degree,  to  prevent  the 
motion  of  the  broken  bone  until  it  is  set;  and  which  efi'ect  nuist  be  lost 
through  the  intervention  of  a  pillow.  I  will  not  say,  that  after  a  certain  time 
has  passed  sulisequent  to  the  accident,  and  owing  to  some  of  the  circum- 
stances which  Mr.  Pott  has  enumerated,  a  limb  may  not  be  so  disordered,  so 
swollen,  inflamed,  and  painful,  that  it  would  be  imprudent,  and  probably  im- 
possible, immediately  to  alter  its  position.  In  that  case,  we  must  wait,  until, 
by  the  assistance  of  fomentations,  poultices,  or  other  proper  applications,  3 
favourable  alteration  takes  place ;  but  these  circumstances  must  indeed  be 
veiy  pressing,  and  the  inflammation  very  great,  which  can  warrant  the  not 
endeavouring  to  get  the  ends  of  the  bones  into  a  proper  position  the  first  time 
of  Seeing  the  fracture;  as  it  is  a  true  and  positive  fact,  that  what  is  most 
likely  10  reduce  the  swelling  and  inflammation,  and  far  beyond  all  topical 
applications,  is  the  even  and  happy  position  of  the  ends  of  the  brokon 
bones.        E. 


328  REMARKS  ON  FRACTURES 

case  will  admit,  the  next  circumstance  to  be  attended  to  is  the 
application  of  some  medicament  to  the  limb;  particularly  to  the 
fractured  part  of  it.  In  this,  different  people  act  differently. 
Some  make  use  of  an  adhesive,  or  what  they  choose  to  call  a 
roborant  plaster;  some,  of  what  is  commonly  called  a  cerecloth; 
others  apply  spirit,  vini,  with  oil,  vinegar,  and  white  of  egg;  and 
others  the  spirit,  mindereri,  the  solution  of  crude  sal  ammoniac  in 
vinegar  and  water,  or  some  such  kind  of  medicine. 

To  the  cerecloth,  provided  it  neither  sticks  to  the  skin,  nor  is 
capable  of  irritating  it,  there  can  be  no  objection;  neither  can 
there  be  any  to  all  the  others,  except  the  adhesive  plaster:  that 
must  for  ever  be  wrong  upon  every  rational  principle.  The  in- 
tention in  applying  any  kind  of  external  medicine  to  a  broken 
limb,  is,  or  ought  to  be,  to  repress  inflammation,  to  disperse  ex- 
travasated  blood,  to  keep  the  skin  lax,  moist,  and  perspirable, 
and  at  the  same  time  to  afford  some,  though  very  small,  de- 
gree of  restraint  or  confinement  to  the  fracture,  but  not  to 
bind  «or  press;  and  it  should  also  be  calculated  as  much  as  pos- 
sible to  prevent  itching,  an  herpetic  eruption,  or  an  erysipelatous 
efflorescence.  Adhesive  plasters  of  all  kinds,  let  the  composition 
of  them  be  what  it  may,  are,  from  this  one  quality,  the  least  likely 
to  contribute  to  any  of  the  good  ends  proposed,  and  the  most  likely 
to  be  the  cause  of  the  contrary  inconveniences,  which  ought  most 
carefully  to  be  avoided.  They  obstruct  perspiration,  they  heat  the 
skin,  tliey  produce  itching,  eruption,  and  inflammation;  and  if  the 
fracture  be  quite  surrounded  by  them,  and  the  limb  be  from  any 
cause  ever  so  little  inclined  to  swell,  they  make  a  tight,  painful, 
and  pernicious  stricture,  much  greater  even  than  a  roller,  and  less 
likely  to  relax.  At  St.  Bartholomew's  hospital,  we  use  a  cerate 
made  by  a  solution  of  lytharge  in  vinegar,  which,  with  soap,  oil, 
and  wax,  is  afterward  formed  into  such  consistence  as  just  to  ad- 
mit being  spread  without  warming. 

This  lies  very  easy,  repels  inflammation,  is  not  adherent,  comes 
off  clean,  and  very  seldom  if  ever  irritates,  or  causes  either  herpes 
or  erysipelas.  But  let  the  form  and  composition  of  the  applica- 
tion made  to  the  limb  be  what  it  may,  one  thing  is  clear;  viz.  that 
it  should  be  put  on  in  such  manner,  as  that  it  may  be  renewed  and 
shifted  as  often  as  may  be  necessary,  without  moving  the  limb  in 


AND  DISLOCATIONS.  229 

any  manner:  it  being  certain,  that  when  once  a  broken  thigh  or 
Jeg  has  been  properly  put  to  rights,  and  has  been  deposited  pro- 
perly on  the  pillow,  it  ought  not  ever  be  lifted  up  or  moved  from 
it  again  without  necessity,  until  the  fracture  is  perfectly  united; 
and  it  is  as  true,  that  such  necessity  will  not  very  often  occur. 
This  may  perhaps  seem  strange  to  those  who  are  accustomed  to 
roll  simple  fractures,  and  consequently  to  lift  them  up  every  three 
or  four  days,  in  order  to  renew  such  kind  of  bandage:  but  the 
necessity  af  this  motion  arises  merely  from  the  kind  of  bandage 
made  use  of,  and  not  from  any  circumstance  of  the  fracture  itself 
That  the  frequent  motion  of  a  fractured  limb  cannot  possibly  con- 
tribute to  the  ease  of  the  patient,  will  I  suppose,  be  readily  admit- 
ted; as  I  suppose  also  it  will,  that  when  a  broken  limb  has  been 
once  deposited  in  the  best  position  possible,  it  is  impossible  to 
mend  that  position;  merely  by  taking  such  limb  up  and  laying  it 
down  again;  from  whence  it  must  follow,  that  such  kind  of  appa- 
ratus as  necessitates  the  surgeon  frequently  to  disturb  the  limb, 
cannot  be  so  good  as  one  that  does  not;  provided  the  latter  will 
accomplish  the  same  kind  of  cure  as  the  former:  the  truth  of 
\vhich  position  will  appear  in  the  most  satisfactory  manner  to  any 
who  will  take  a  view  of  the  method  in  which  simple  fractures  are 
treated  at  the  before-mentioned  hospital.  Such  application  hav- 
ing been  made  as  the  surgeon  thinks  right,  the  next  thing  to  be 
done  is  to  put  on  a  proper  bandage.  That  used  by  the  ancients, 
and  by  the  majority  of  the  present  practitioners,  is  what  is  com- 
monly called  a  roller.  This  is  of  different  length,  according  to 
the  surgeon's  choice,  or  as  it  may  be  used  in  the  form  of  one,  two, 
or  more  pieces.  Hippocrates  used  three°;  Celsus,  six;  but  the 
present  people  seldom  use  more  than  one.  By  such  kind  of  band- 
age three  intentions  are  aimed  at,  and  said  to  be  accomplished;  viz. 
to  confine  the  fracture,  to  repress  or  prevent  a  flux  of  humours,  and 
to  regulate  the  callus"^:  but  whoever  will  reflect  seriously  on  this 

«  See  on  this  subject  Fab.  ab  Aquapendenle,  Wiseman,  Sculletus,  Hildanus, 
Petit,  Du  Verney. 

••."On  applique  la  premiere  sur  I'enclroit  meme  de  la  fracture.  Son 
'•  milieu  doit  repondre  au  centre.  On  fait  trois  tours  circiiliiires :  ce  qui 
"  sert  affermir  cet  endroit,  qui  est  le  seul  qui  ait  besoin  d'etre  assvijetti, 
"  comrae  etant  le  seul  qui  peut  se  deranger,  et  a  contmir  le  sue  nouncier,  et 


230  REMARKS  ON  FRACTURES 

matler  will  soon  be  convinced,  that  although  some  sort  of  band- 
age is  necessary  in  every  simple  fracture,  as  well  for  preserving 
some  degree  of  steadiness  to  the  limb,  as  for  the  retention  of  the 
applications,  yet  none,  nor  neither  of  these  three  ends  can  be 
answered  merely,  or  even  principally,  by  bandage  of  any  kind 
whatever;  and  therefore,  if  this  should  be  found  to  be  true — that 
is,  if  it  should  appear  that  whatever  kind  of  deligation  be  made 
use  of,  it  cannot  be  a  principal,  but  only  an  accessorial  kind  of 
assistance,  and  that  in  a  small  degree,  and  very  little  to  be  de- 
pended upon — it  will  follow,  that  such  kind  of  bandage  as  is  most 
difficult  to  be  applied  with  justness  and  exactitude,  such  as  is 
soonest  relaxed  and  out  of  order,  such  as  stands  most  frequently  in 
need  of  renewal,  and  in  such  renewal  is  naost  likely  to  give  pain 
and  trouble,  must  be  more  improper  and  less  eligible  than  one 
which  is  more  easily  applied,  less  liable  to  be  out  of  order,  and 
which  can  be  adjusted  without  moving  the  limb. 

The  ancient  method  of  applying  the  roller  in  case  of  simple 
fracture  of  the  leg  or  thigh,  was  to  make'  four  or  five  turns  round 
the  fracture  first,  and  then  to  continue  the  bandage  upward  and 
downward,  until  the  whole  limb  was  enveloped  properly.  This 
was  done  in  this  manner  with  a  double  view;  to  keep  the  broken 
ends  of  the  bone  in  their  place,  and  to  prevent  the  influx  of  hu- 
mour. Modern  practitioners,  although  they  have  the  same  ends 
in  view,  generally  begin  their  bandage  from  the  inferior  extremity 
of  the  limb,  and  continue  it  up  to  the  top.  Whether  the  old  or  the 
later  method  be  followed,  whether  one  or  more  rollers  be  made  use 
of,  the  whole  is  executed  while  the  limb  is  kept  by  means  of  the 
assistants  in  the  same  extended  posture  in  which  the  coaptation 
was  made,  so  that  the  whole  bandage  is  finished  before  the  leg  is 
deposited  on  the  pillow;  in  the  doing  all  which,  if  from  the  tired 
state  of  the  surgeon,*  or  either  of  his  assistants,  or  if  from  the 

"  empecher  qii''il  ne  s'echappe  tvop  abondamment  et  trap  irrc^iilieremcnt  a  Pentour 

"  de  la  fracture  ;  ce  qiiiferoit  un  cal  tres  diffhrme." 

Du  Vf.uxet. 

eSee  a  particular  account  of  this  in  Fab.  ab.  Aquapendente,  and  in  Ser- 
geant Wiseman. 

*  T'lie  extraordinary  length  of  time  used  by  some  in  putting  a  fracture  t» 
rights,  renders  what  1  have  called  the  tired  state  of  the  assissants  an  object  of 


AND  DISLOCATIONS.  231 

awkwardness,  or  unhandiness  of  any  of  the  parties  concerned,  the 
true  and  exact  position  of  the  limb  be  at  all  deviated  from,  the 
ends  of  the  bone  will  again  be  in  some  degiee  displaced,  and  the 
bandage,  instead  of  being  of  use,  will  become  prejudicial,  by 
pressing  hard  on  the  inequalities  of  the  fracture:  to  which  let  me 
add,  that  the  roller,  especially  when  applied  to  a  leg,  if  it  be  not 
put  on  with  due  dexterity,  that  is,  if  it  do  not  sit  perfectly  smooth 
and  even,  is  the  most  unequal  and  worst  kind  of  bandage  in  use. 

These  objections,  however  just,  are  not  the  least  to  which  the 
roller  in  the  case  of  simple  fracture  of  the  leg  or  thigh  are  liable; 
for,  as  I  have  already  hinted,  it  must  in  a  very  short  space  of 
time,  even  while  the  parts  surrounding  the  fracture  are  in  the 
most  tender  and  most  painful  state,  be  renewed,  and  that  more 
than  once,  which  renewal  cannot  be  executed  without  again  tak- 
ing the  limb  off  from  the  pillow,  again  committing  it  to  the  hands 
of  assistants,  and  again  running  a  risk  of  displacing  the  fracture: 
all  which,  not  to  mention  the  repetition  of  pain  to  the  patient 
every  time  such  operation  is  performed,  and  which  must  be  at 
least  every  four  or  five  days,  are  (as  I  have  already  said)  very 
material  objections  to  the  roller,  even  in  the  most  judicious  and 
dexterous  hands,  and  still  more  so  in  those  of  the  rude  and  igno- 
rant. 

The  prevention  of  a  flux  of  humours  to  a  broken  limb  by 
bandage,  is  a  common  phrase;  but  they  who  use  it,  have  either  no 
idea  at  all  annexed  to  it,  or  a  very  erroneous  one. 

If  by  the  points  and  edges  of  the  broken  bone,  the  muscles  and 
membranes  be  unavoidably  wounded  and  torn,  or  if  the  same  kind 
of  mischief  be  incurred  by  the  inadvertence  or  indiscretion  of  the 
patient,  or  of  those  who  assisted  in  getting  him  home,  or  from  the 
violence  used  in  extending  the  limb  and  setting  the  fracture,  inflam- 
mation must  be  excited,  and  pain  and  tumefaction  will  be  the  con- 
sequence; and  these  will  continue  for  some  time  in  every  fracture; 
but  that  space  will  be  longer  or  shorter  in  diflerent  cases  and  un- 
der different  circumstances:  evacuation,  rest,  and  a  favourable 

importance.  The  good  position  of  the  fracture  depends  as  much  or  more  on 
tlfem  than  on  the  surgeon.  If  the  assistant  who  holds  the  foot  varies  fi-om 
the  proper  manner,  I  defy  the  surgeon  to  redress  the  fracture  without  the 
concurrence  of  such  assistant. 


232  REMARKS    ON   FRACTURES 

position  of  the  limb,  will,  and  do  in  general,  remove  all  these 
complaints;  but  bandage  can  contribute  nothing  more  than  by 
keeping  the  applications  in  their  proper  place;  so  far  from  it,  that 
if  the  bandage  be  a  roller,  it  must  by  the  frequent  necessity  of  its 
being  adjusted,  and  the  frequent  motion  of  the  limb,  in  some  de- 
gree counteract  the  proper  intention  of  cure. 

The  old  writers  are  in  general  very  precise  as  to  the  number  of 
days  during  which  the  roller  should  be  suffered  to  remain  without 
being  shifted;  and  the  number  of  times  which  such  shifting  should 
be  repeated  within  the  first  fortnight.g  This  exactitude  is  by  no 
means  necessary;  but  if  the  bandage  be  supposed  to  be  of  any  use 
at  all,  it  is  obvious,  that  it  ought  to  be  renewed  or  adjusted  as 
often  as  it  may  cease  to  perform  the  office  for  which  it  is  designed, 
or  whenever  it  shall  be  found  to  counteract  such  office;  that  is,  as 
often  as  it  shall  become  so  slack  as  not  to  contain  the  fracture  at 
all;  or  whenever  the  limb  shall  be  so  swollen,  that  the  roller 
makes  an  improper  degree  of  stricture.  The  former  generally 
occurs  every  four  or  five  days:  the  latter  is  most  frequeni  within 
the  first  week. 

In  most  of  the  writers  on  the  subject  of  fractures,  we  also  find 
marks  or  signs  laid  down  for  our  information  concerning  the  due 
or  undue  effect  of  the  bandage  on  the  limb.  They  tell  us,  that 
when  that  part  of  it  which  is  below  the  termination  of  the  roller 
does  not  swell  at  all,  that  the  bandage  is  not  sufficiently  strict, 
and  will  not  retain  the  fracture;  that  when  the  same  part  is  con- 
siderably swollen,  or  tense,  or  inflamed,  it  implies,  that  the  bind- 
ing is  too  straight;  and  that  a  moderate  degree  of  tumefaction  is  a 
sign  that  the  deligation  is  properly  executed.'^ 

«  **Tertio  die  a  deligatione  facta,  Hippocrates  fascias  resolvit,  &c.  Facta 
"  bona  deligatura  et  pruritu  non  insectante,  a  tertio  usque  ad  septimum  opor- 
"  tet  aegrum  deligatum  detinere. 

"  Septimo  membrum  rursus  solvendum,  perfundendum  aqua  tepida,  et 
*f  ligandum. 

Fab.  AB   AatTAPENBEKTE. 

*  See  on  this  Fab.  ab  Aquapendente,  who  speaks  or  rather  copies  the  sen- 
timents of  Hippocrates  and  Celsus.  "  Terminus  in  stringendo  debet  esse 
"  bonalaborantis  tolerantia:  ut  deligatum  leviter  premat,  et  sic  turn  contineat 
"  et  stabiliat  fracturam,  turn  humores  exprimat.  Sunt  eliam  alia  luijus  signa, 
"  qux  altero  die  apparent ;  si  enim  scger  eo  die  quo  deligatus  sentiat  se  valen- 


AND  DISLOCATIONS.  233 

In  consequence  of  these  precepts,  many  practitioners  look  more 
anxiously  after  this  degree  of  tumefaction,  than  after  the  true  and 
exact  position  of  the  limb;  and  cannot  be  induced  to  believe,  that 
imy  thing  can  be  wrong  under  this  appearance;  although,  if  they 
would  for  once  assume  the  liberty  of  thinking  for  themselves, 
they  might  be  convinced,  that  even  this  degree  of  swelling  is 
wrong;  that  it  implies  some  kind  of  obstruction  to  the  circulation, 
and  cannot  serve  any  good  purpose;  and  consequently,  that  as  far 
as  it  may  be  supposed  to  be  the  effect  of  bandage,  so  far  that  band- 
age must  be  faulty. 

The  third  purpose  for  which  the  roller  is  said  to  be  used,  is  the 
regulation  and  restraint  of  the  callus. 

If  we  were  to  form  our  notion  of  callus  by  what  the  generality 
of  writers  have  said  on  this  subject,  we  should  suppose,  that  it  was 
not  only  a  particular  juice  always  ready  for  the  purpose,  but  that, 
if  not  restrained  and  regulated  by  art,  it  would  always  flow  in 
such  quantity,  as  to  create  trouble  and  deformity;  that  there  were 
specific  remedies  for  increasing  or  decreasing  it;  and  that  it  al- 
ways required  the  hand  and  art  of  surgery  to  manage  it.  That 
the  callus  is  so  far  a  particular  juice,  as  that  it  consists  of  what- 
ever is  destined  to  circulate  through  the  bones  for  their  particular 
Bourishment,  is  beyond  all  doubt;  and  that  this  gelatinous  kind  of 
fluid  is  the  medium  by  which  fractures  are  united,  is  as  true;  but 
that  it  requires  art  to  manage  it,  or  that  art  is  in  general  capable 
of  managing  and  directing  it,  is  by  no  means  true.  That  this 
callus  or  uniting  medium  does  oftentimes  create  tumefaction  and 
deformity,  or  even  lameness,  is  true  also;  but  the  fault  in  these 
cases  does  not  lie  in  the  mere  redundance  of  such  juice;  it  is  de- 
rived from  the  nature  of  the  fracture,  from  the  inequality  of  it 
when  set,  and  from  the  inapt  position  of  the  broken  ends  with 
regard  to  each  other;  nor  is  surgery  or  the  surgeon  any  otherwise 

••  tius  stringi,  postero  vero  die  tumor  laxus,  mollis  et  parvus  appareat,  bona 
"  est  deiigatio,  quia  jam  humores  a  parte  fracta  sunt  expressi.  Si  vero  aut 
"  nullus  tumor  aut  magnus  et  durus  postridie  in  manu  vel  pede  appareat,  pra- 
"  va  est  deligatura ;  quia  ilia  non  continet,  haec  vero  nimis  arcta  est  et  inflam- 
*•  mationem  movet.  Id  notandum,  fascias  magis  stinngi  debere  in  parte  fracta 
*•  quam  alibi,  ut  pars  fracta  magis  illsesa  servetur,  ab  humorum  defluxu." 
VOL  T.  G  g 


234  REMARKS  ON  FRACTURES 

blamable  in  Ibis  case,  tban  as  it  was  or  was  not  originally  in 
tbeir  power  to  bave  placed  tbem  better.     It  is  the  inequality  of 
the  fracture  which  makes  both  the  real  and  apparent  redundance 
of  callus,  and  the  tumefaction  in  the  place  of  union.     When  a 
bone  has  been  broken  transversely,  or  nearly  so,  and  its  inequali- 
ties are  therefore  neither  many  nor  great,  when  such  broken  parts 
have  been  happily  and  properly  coaptated,  and  proper  methods 
have  been  used  to  keep  them  constantly  and  steadily  in  such 
state  of  coaptation,  the  divided  parts  unite  by  the  intervention  of 
the  circulating  juice,  just  as  the  softer  parts  do,  allowing  a  differ- 
ent space  of  time  for  different  texture  and  consistence.     When 
the  union  of  a  broken  bone  under  such  circumstances  has  been 
procured,  the  place  where  such  union  has  been  made  will  be  very 
little  perceptible;  it  will  be  no  deformity,  nor  will  it  occasion  any 
inconvenience.     It  will  indeed  be  discoverable,  like  a  cicatrix  of 
a  wound  in  a  softer  part;  but  there  will  be  noredundance  of  cal- 
lus, because  none  will  be  wanted:  neither  will  there  be  any  neces- 
sity for  any  particular  management,  on  the  part  of  the  surgeon,  to 
repress  or  keep  it  in  order.     But  when  a  bone  has  been  broken 
very  obliquely  or  very  unequally,  when  the  parts  of  a  fracture  are 
so  circumstanced  as  not  to  admit  of  exact  coaptation,  when  such 
exact  coaptation  as  the  fracture  perhaps  would  have  admitted  has 
not  been  judiciously  made,  when,  from  unmanageableness,  inad- 
vertence, or  spasm,  the  proper  position  of  the  limb  has  not  been 
attended  to  or  preserved,  in  all  such  cases  there  must  be  consider- 
able inequality  of  surface;  there  must  be  risings  on  one  side,  and 
depressions  on  another;  and  in  such  cases  the  juices  circulating 
through  the  bone,  cannot  accomplish  the  union  in  the  same  quan- 
tity, the  same  time,  or  in  the  same  manner.     The  broken  parts 
not  being  applied  exactly  to  each  other,  there  cannot  be  the  same 
aptitude  to  unite;  and  according  to  the  greater  or  less  degree  of 
exactitude  in  the  coaptation,  that  is,  according  as  the  ends  of  the 
bones  are,  or  have  been  placed  more  or  less  even  with  regard  to 
each  other,  will  the  inconvenience  and  the  deformity  be;  and  sUll 
mqre  where  the  fracture  is  not  set  at  all:  but  the  broken  ends  of 
the  bone  unite  laterally,  or  by  touching  each  other's  sides.     The 
reason  of  all  this  is  so  obvious,  without  having  recourse  to  a  par- 
ticular specific  juice  under  the  name  of  callus,  that  it  would  be 


J-rmt  page  2Si.  Vol.  J. 


En^.    by  IU'lIi 


AND  DISLOCATIONS.  2S5 

an  insult  upon  the  reader's  understanding  to  explain  it  further.' 
The  periosteum  covering  every  fracture  will  remain  thickened  for 
some  time,  and  a  degree  of  fulness  or  rising  will  be  thereby  caus- 
ed about  the  place  where  such  fracture  has  been  united;  but  time, 
and  the  use  of  the  muscles,  soon  in  general  remove  this. 

In  short  this  doctrine  of  callus,  considered  as  a  particular  kind 
of  juice,  and  as  being  liable  to  great  redundance  if  not  prevented 
by  art,  has  not  only  misled  many  people,  but  has  often  been  made 
use  of  as  a  cover  to  ignorance  and  neglect.  When  lameness  and 
deformity  have  been  the  consequences  of  one  or  both  these  causes, 
more  than  of  the  nature  and  circumstances  of  a  fracture,  the  callus 
has  been  found  ready  at  hand  to  take  the  blame;  and  the  ideal  ex- 
■  uberance  of  this  cement  has  often  been  urged  as  an  excuse  for  real 
want  of  knowledge,  or  for  gross  neglect. 

The  best  and  most  useful  bandage  for  a  simple  fracture  of  the 
leg  or'  thigh,  is  what  is  commonly  known  by  the  name  of  the 
eighteen-tailed  bandage,''  or  rather  one  made  on  the  same  prin- 
ciple, but  with  a  little  difference  in  the  disposition  of  the  pieces. 
The  common  method  is  to  make  it  so,  that  the  parts  which  are  to 
surround  the  limb,  make  a  right  angle  with  that  which  runs 
lengthways  under  it;  instead  of  which,  if  they  are  tacked  on  so  as 
to  make  an  acute  angle,  they  will  fold  over  each  other  in  an  oblique 
direction,  and  thereby  sit  more  neatly  and  more  securely,  as  the 
parts  will  thereby  have  more  connexion  with  and  more  depen- 
dence on  each  other.  In  compound  fractures,  as  they  are  called, 
every  body  sees  and  acknowledges  the  utility  of  this  kind  of 
bandage  preferable  to  the  roller,  and  for  very  obvious  and  con- 
vincing reasons,  but  particularly  because  it  does  not  become  ne- 
cessary to  lift  up  and  disturb  the  limb  every  time  it  is  dressed,  or 
every  time  the  bandage  loosens. 

The  pain  attending  motion  in  a  compound  fracture,  the  circum- 

'  On  the  subject  of  callus,  the  editor  of  Du  Verney  tells  a  story  from  Galen, 
and  which  himself  seems  not  to  disbelieve,  viz.  that  a  callus  in  a  particular 
case  was  so  redundant  as  to  transude  through  the  skin,  and  to  keep  the  com- 
presses  constantly  wet. 

"  Perhaps  more  properly  the  many-tailed  bandage,  as  the  number  of  tails 
or  ends  must  depend  on  the  length  of  the  limb,  and  other  circumstances  rela- 
tive to  the  fracture.        E. 


236  REMARKS  ON  FRACTURES 

Stance  of  the  wound,  and  the  greater  degree  of  instability  of  parts 
thereby  produced,  are  certainly  very  good  reasons  for  dressing 
such  wound  with  a  bandage,  which  does  not  render  motion  neces- 
sary; but  I  should  be  glad  to  know  what  can  make  it  necessary, 
or  right,  or  eligible,  to  move  a  limb  in  the  case  of  simple  fracture? 
what  benefit  can  be  proposed  by  it?  what  utility  can  be  drawn 
from  it?  When  a  broken  bone  has  been  well  set,  and  the  limb 
well  placed,  what  possible  advantage  can  arise  from  moving  it? 
surely  none;  but,  on  the  contrary,  pain  and  probable  mischief.  Is 
it  not  the  one  great  intention  to  procure  unition?  Can  moving  the 
limb  every  two  or  three  days  contribute  to  such  intention?  Must 
it  not  on  the  contrary  obstruct  and  retard  it?  Is  not  perfect  quie- 
tude as  necessary  towards  the  union  of  the  bone  in  a  simple  as 
in  a  compound  fracture?  It  is  true,  that  in  the  one  there  is  a 
wound  which  requires  to  be  dressed,  and  the  motion  of  the  limb 
may  in  general  be  attended  with  rather  more  pain  than  in  the 
other:  but  does  motion  in  the  simple  fracture  give  ease,  or  procure 
more  expeditious  union? 

Every  benefit  then  wdiich  can  be  supposed  to  be  obtained  from 
the  use  of  the  common  bandage  or  roller,  is  equally  attainable 
from  the  use  of  that  which  I  have  just  mentioned,  with  one  ad- 
ditional, and,  to  the  patient,  most  invaluable  advantage;  viz.  that 
of  never  finding  it  necessary  to  have  his  leg  or  thigh  once  during 
the  cure  removed  from  the  pillow  on  which  it  has  been  properly 
deposited.  In  short,  to  quit  reasoning  and  speak  to  fact,  it  is  the 
constant  practice  at  St.  Bartholomew's,  and  attended  with  all 
possible  success.  We  always  use  the  eighteen-tailed  bandage; 
and  never  move  the  limb  to  renew  or  adjust  it.' 

The  parts  of  the  general  apparatus  for  a  simple  fracture,  which 
come  next  in  order,  are  the  splints. 

These  are  generally  made  of  pasteboard,  wood,  or  some  resist- 
ing kind  of  stuff,  and  are  ordered  to  be  applied  lengthways  on  the 
broken  limb;  in  some  cases  three,  in  others  four;  for  the  more 
steady  and  quiet  detention  of  the  fracture. 

That  splints  properly  made  and  judiciously  applied  are  very 

J  See  the  different- opinions  of  different  French  practitioners,  with  tlieir 
reasons  on  this  subject,  in  Dii  Verney,  Traite  des  Maladies  des  Os. 


ANV  DISLOCATIO>f^.  237 

serviceable,  is  beyond  all  doubt;  but  tbeir  utility  depends  much 
on  their  size  and  the  manner  in  which  they  are  applied. 

In  general  practice,  they  are  made  of  such  length,  as  not  to 
reach  either  upward  or  downward,  so  far  as  the  roller  extends'; 
not  to  comprehend  either  the  upper  or  the  lower  joint  of  the 
broken  bone,  and  to  exceed  the  fracture  either  way  not  many 
inches.  They  do  not,  for  example,  in  the  broken  leg  compre- 
hend either  the  joint  of  the  knee,  or  the  joint  of  the  ancle,  and 
act  only  on  the  fracture.™ 

In  this  manner  of  application,  and  of  this  size,  they  are  in  fact 
neither  more  nor  less  than  compresses,  and  compresses  made  of 
very  bad  materials.  All  the  good  that  ever  is,  or  that  can  be 
done  by  them,  when  of  such  length  and  so  applied,  might  cer- 
tainly be  done  in  a  better  manner  by  a  more  proper  kind  of  com- 
press; and  every  disadvantage,  which  a  hard  resisting  compress, 
injudiciously  applied,  is  capable  of  producing,  is  probable  to  result 
from  them  thus  used. 

"'  Tliis  is  the  old  doctrine,  and  has  been  ahnost  universally  and  constantly 
adhered  to  and  followed.  Our  forefathers,  finding  that  siicli  splinls  as  they 
used  and  applied  in  their  manner  excited  pain  and  inflammation,  did  not  use, 
but  forbade  them  until  after  seven  days  were  past,  and  the  first  inflammation, 
as  they  thought,  was  over. 

After  this,  they  put  them  on  to  strengthen  the  fracture,  as  they  said,  and 
therefore  made  them  short  for  that  purpose  only,  expressly  cautioning  us 
against  the  only  method  of  applying  them  (in  the  case  of  a  broken  leg)  in 
which  they  can  be  really  useful ;  viz.  that  in  which  they  comprehend  both  the 
knee  and  ancle. 

"  Feri|larum  usus  idem  est  ac  pannorum  ad  fractum  os  continendum,  ut 
"  maneat  immotum,  etiamsi  membrum  universum  moveatur. 

"  Jubet  Hippocrates  leves  esse  ferulas  et  aequales  et  ad  extrema  resi- 
"  mas,  &c. 

"  Sed  et  breviores  ferulas  esse  prsecipit  ipsa  vinciwa,  ne  quando  cutem 
•"  proximam  tentare  valeant  eminentem  plerumque  ob  humores  receptos, 
"  quos  fasciae  exturbant.  Id  quoque  cavere  oportet,  ne  ad  ossium  eminentias, 
"  quales  in  ima  tibia  et  sura  sunt,  ferulse  pertingant,"  &.c.  &.c.  &c. 

OuiBASius  de  Fracturis. 

"  Sed  hoc  tempore  (post  septimum  diem)  vice  plagularum  ojiortet  ferulas 
"  opponere. 

"  His  utebatur  Hippocrates  demum  post  septimum  diem  ;  quia  ante  septi- 
"  mum  magis  urgebat  intentio  arcendse  inflammationis,  quam  intentio  stabili- 
'^  endi  fracturam ;  post  septimum  autem  contra  acciuit." 

Fab.  AB  AaUAPEJfDENTE. 


238  REMARKS  ON  FRACTURES 

The  true  and  proper  use  of  splints  is,  to  preserve  steadiness  in 
the  whole  limb,  without  compressing  the  fracture  at  all.  By  the 
former  they  become  very  assistant  to  the  curative  intention;  by  the 
latter  they  are  very  capable  of  causing  pain  and  other  incon- 
veniences; at  the  same  time  that  they  cannot,  in  the  nature  of 
things,  contribute  to  the  steadiness  of  the  limb. 

In  ofder  to  be  of  any  real  use  at  all,  splints  should,  in  the  case 
of  a  broken  leg,  reach  above  the  knee  and  below  the  ancle;  should 
be  only  two  in  number;  and  should  be  so  guarded  with  tow,  rag, 
or  cotton,  that  they  should  press  only  on  the  joints,  and  not  at  all  on 
the  fracture. 

By  this  they  becbme  really  serviceable;  but  a  short  splint, 
which  extends  only  a  little  above  and  a  little  below  the  fracture, 
and  docs  not  take  in  the  two  joints,  is  an  absurdity;  and,  what  is 
tvorse,  it  is  a  mischievous  absurdity. 

By  pressing  on  both  joints,  they  keep  not  only  them  but  the 
foot  steady;  by  pressing  on  the  fracture  only,  they  cannot  retain 
it  in  its  place,  if  the  foot  be  in  the  smallest  degree  displaced;  but 
they  may,  and  frequently  do  occasion  mischief,  by  rudely  pressing 
the  parts  covering  the  fracture  against  the  edges  and  inequali- 
ties of  it. 

I  suppose  it  will  be  said,  that  although  short  splints  do  not  of 
themselves  sustain  and  keep  steady  the  two  joints,  and  conse- 
quently the  limb,  yet  that  purpose  in  the  broken  leg  may  be,  and 
is,  fulfilled  by  junks,  fanons,  and  other  contrivances.  To  which 
I  answ^er,  that  then  the  short  splints  are  in  that  case  of  no  use  at 
all,  and  had  better  be  laid  aside:  they  should  be  used  for  no  other 
purpose,  but  that  of  keeping  the  limb  steady;  and,  if  they  do  not 
answer  that  end,  they  are  an  incumbrance,  and  multiply  the  arti- 
cles in  the  apparatus  for  a  fractured  leg  very  unnecessarily. 

In  the  case  of  a  fractured  os  femoris,  if  the  limb  be  laid  in  an 
extended  posture,  one  splint  should  certainly  reach  from  the  hip 
to  the  outer  ancle,  and  another  (somewhat  shorter)  should  extend 
from  the  groin  to  the  inner  ancle.  In  the  case  of  a  broken  tibia 
and  fibula,  there  never  can  be  occasion  for  more  than  two  splints, 
one  of  which  should  extend  from  above  the  knee  to  below  the 
ancle  oa  one  side,  and  the  other  splint  should  do  the  same  on  the 


AND  DISLOCATIONS. 


239 


other  side.     The   manner  of  applying  them,  if  the  limb  l)e  de- 
posited in  a  state  of  flexion,  will  come  under  the  next  article. 

This,  and  indeed  the  most  essential  article  in  the  treatment  of 
a  fracture,  is  the  position  of  the  limb.  Upon  tiie  judicious  or  in- 
judicious, the  proper  or  improper  execution  of  this,  depends  the 
ease  of  the  patient  during  his  confinement,  and  the  free  use  and 
natural  appearance  of  his  limb  afterward. 

If  I  meant  to  describe,  or  if  I  approved  (pardon  the  phrase)  the 
common  method  of  placing  the  broken  leg  and  thigh  in  a  straight 
manner,  this  would  be  the  place  to  mention  the  many  very  in- 
genious contrivances  and  pieces  of  machinery,  which  practitioners, 
both  ancient  and  modern,  have  invented  for  the  purpose  of  keep- 
ing the  whole  limb  straight  and  steady;  that  is,  of  keeping  all  the 
muscles  surrounding  the  fractured  bone  constantly  upon  the  stretch, 
and  at  the  same  time  of  preventing  any  inequality  in  the  union 
of  it,  and  any  shortening  of  the  limb,  in  consequence  of  such 
inequality. 

But  as  it  is  my  intention  by  these  sheets  to  inculcate  another, 
and  as  it  appears  to  me  a  better  disposition  of  the  limb,  in  which 
such  boxes,  cradles,  and  pieces  of  machinery  are  not  wanted,  nor 
can  be  used,  it  is  needless  for  me  to  say  any  thing  about  them. 

According  to  this  plan  the  fractured  leg  and  thigh  should  be 
deposited  on  the  pillow,  in  the  very  posture  in  which  the  extension 
was  made,  and  the  fracture  set;  that  is,  with  the  knee  bent. 

I  have  already  been  so  explicit,  or  perhaps  prolix,  on  the  tense 
or  lax  state  of  the  muscles,  as  depending  on  posture,  under  the 
head  of  extension,  that  I  shall  spare  the  reader,  as  well  as  myself, 
a  good  deal  of  trouble  by  referring  back  to  that  article.  All  that 
is  there  urged,  or  that  can  be  urged  for  making  the  extension,  that 
is,  for  setting  a  fracture  in  such  disposition  of  a  limb  or  its  mus- 
cles, is  equally  powerful  and  conclusive  ivith  regard  to  the  man- 
ner of  depositing  and  leaving  it  after  it  has  been  set.  Whatever 
renders  reduction  and  coaptation  easy,  must  as  necessarily  main- 
tain ease  during  the  confinement,  preserve  rectitude  of  figure,  and 
prevent  displacement.  The  same  principle  must  act  on  both 
occasions;  and  whether  the  doctrine  be  right  or  WTong,  considered 
by  itself,  it  must  be  equally  so  in  both  circumstances;  that  is,  in 
the  manner  of  setting  a  fracture,  and  in  the  r^anner  of  depositing 


240  REMARKS  ON  FRACTURES 

the  limb  afterwartl."  In  the  case  of  the  fractured  os  humeri,  the 
only  position  in  which  it  can  with  any  tolerable  convenience  to 
the  patient  be  placed,  is,  with  the  elbow  bent,  that  very  position 
which  necessarily  relaxes  and  removes  all  the  resistance  of  the 
surrounding  muscles.  Daily  experience  evinces  the  utility  of  this,. 
by  our  very  seldom  meeting  with  lameness  or  deformity  after  it, 
notwithstanding  the  prevailing  apprehension  of  exuberant  callus. 

The  deformity  frequently  consequent  to  the  fracture  of  the 
bones  of  the  cubit,  particularly  that  of  the  radius  only,  will  gene- 
rally, if  not  always,  be  found  to  be  in  proportion  as  the  muscles 
concerned  in  the  pronation  and  supination  of  the  hand  happen  to 
be  put  more  or  less  into  a  state  of  action,  or  tension,  by  the  position 
of  the  limb. 

In  the  thi^h,  the  case  is  still  more  obvious,  as  the  muscles  are 
still  more  numerous  and  stronger. 

The  straight  posture  puts  the  majority  of  them  into  action,  by 
which  action  that  part  of  the  broken  bone,  which  is  next  to"  the 
knee,  is  pulled  upward,  and  by  passing  more  or  less  underneath 
that  part  which  is  next  to  the  hip,  makes  an  inequality  or  rising 
in  the  broken  part,  and  produces  a  shortness  of  the  limb. 

In  the  fracture  of  both  bones  of  the  leg,  the  case  is  still  the 
same;  a  straight  position  puts  the  muscles  upon  endeavouring  to 
act;  a  moderate  flexion  of  the  knee  relaxes  them,  and  takes  off 
such  propensity." 

The  disposition,  therefore,  of  the  broken  cubit  ought  to  be  that 
which,  by  putting  the  hand  into  a  middle  state  between  prona- 
tion and  supination,  and  by  bending  the  fingers  moderately,  keeps 
the  radius  superior  to  the  ulna;  or  in  other  words,  the  palm  of  the 
hand  should  be  applied  to  the  breast,  the  thumb  should  be  supe- 

"  It  has  been  said,  that  the  straight  position  of  a  limb,  by  putting  the  miis- 
cles  on  the  stretch,  induces  t!iem  to  contribute  to  the  security  of  the  frac- 
ture against  displacement.  If  this  be  the  case  ih  general,  how  happens  it 
that  those  bones  are  always  found  most  liable  to  be  displaced  when  broken, 
and  to  be  most  difficult  to  keep  in  their  proper  place,  which  are  surrounded 
by  the  most,  and  by  the  strongest  muscles  ? 

•  In  proportion  as  the  fracture  shall  happen  to  be  more  or  less  oblique,  the 
truth  of  this  doctrine  will,  upon  experiment,  be  found  to  be  more  or  less 
apparent,  3is  well  as  ujscful. 


ANl)   DISLOCATIONS.  241 

rior,  the  little  finger  inferior;  and  the  hand  should  be  kept  in  this 
posture  constantly  by  means  of  two  splints;  which  should  reach 
from  the  joint  of  the  elbow  on  each  side,  and  should  be  extended 
below  the  fingers;  or  the  same  purpose  may  be  still  better  an- 
swered by  a  simple  neat  contrivance  of  the  very  ingenious  Mr. 
Gooch  of  Norfolk;  of  which  he  has  given  a  draft,  and  which  is 
preferable  to  a  common  splint,  by  its  admitting  the  fingers  to  be 
more  easily  bent. 

The  position  of  the  fractured  os  femoris  should  be  on  its  out- 
side, resting  on  the  great  trochanter;  the  patient's  whole  body 
should  be  inclined  to  the  same  side;  the  knee  should  be  in  a  mid- 
dle state,  between  perfect  flexion  and  extension,  or  half  bent;  the 
leg  and  foot  lying  on  their  outside  also,  should  be  well  supported  by 
smooth  pillows,  and  should  be  rather  higher  in  their  level  than 
the  thigh;  one  very  broad  splint  of  deal,  hollowed  out,  and  well 
covered  with  wool,?  rag,  or  tow,  should  be  placed  under  the 

P  If  tlie  pillow  on  which  the  broken  thigh  is  placed  be  not  too  thick,  the 
splint  may  with  equal  advantage  be  placed  underneath  such  pillow,  and  in 
many  cases  this  will  be  found  to  be  the  best  manner  of  using  it.* 

•  Of  late  years  Mr.  Pott  was  not  partial  to  the  use  of  pillows ;  and  I 
have  often  heard  him  object  to  their  being  placed  between  the  splint  and  the 
limb  ;  indeed,  in  general,  our  intentions  are  better  effected  without  any.  I 
would  take  the  liberty  to  recommend,  in  fractures  of  the  leg  or  thigh,  so 
soon  as  the  bones  are  set,  and  the  limb  placed  in  a  proper  position  on  a  splint, 
that  it  be  gently  laid  on  the  bed,  previously  made  firm,  smooth,  and  level.  In 
this  manner  it  lies  on  a  foundation  to  be  depended  on  :  if  a  pillow  be  placed 
under  a»fractured  leg,  it  elevates  it  above  the  level  of  the  body,  and  the 
thigh  remains  unsupported.  If  another  be  placed  under  the  thigh,  though 
it  may  in  some  measure  obviate  this  inconvenience,  it  is  very  liable  to  be 
displaced.  In  general,  the  elevation  of  ihe  leg,  so  far  from  being  necessary, 
is  prejudicial ;  the  limb  will  lie  with  much  more  ease  and  security  when  on 
a  level  with  the  pelvis :  the  bed  therefore  cannot  be  made  too  flat.  If  it  be 
thought  necessary  to  raise  the  limb  higher,  in  order  to  serve  any  particular 
purpose,  pillows  or  double  blankets  may  be  very  conveniently  placed  under 
the  bed  :  by  these  means  a  broad  steady  basis  will  still  be  preserved  for  the 
support  of  the  fractured  limb.  With  regard  to  applying  pillows  between 
the  limb  and  the  splint,  I  must  observe,  that  they  cannot  be  thus  used  to 
advantage,  as  they  take  from  the  proper  stability  and  pressure  of  the  splint, 
and  give  the  fractured  ends  of  the  bones  too  much  play.  The  nearer  and 
closer  the  splints  are  to  the  limb  the  better,  provided  they  are  prevented 
from  galling  by  the  interposition  of  some  soft  substance,  snch  aa  tmv  or 
rag.        E. 

VOL.  I.  H  h 


242  REMARKS  ON  FRACTURES 

thigh,  from  above  the  trochanter,  quite  below  the  knee;  and  an- 
other, somewhat  shorter,  should  extend  from  the  groin  below  the 
kriee  on  the  inside,  or  rather  in  this  posture  on  the  upper  side; 
the  bandage  should  be  of  the  eighteen-tail  kind;  and  when  the 
bone  has  been  set,  and  the  thigh  well  placed  on  the  pillow,  it 
should  not,  without  necessity  (which  necessity  in  this  m  thod 
will  seldom  occur)  be  ever  moved  from  it  again  until  the  frac- 
ture is  united;  and  this  union  will  always  be  accomplished  in 
more  or  less  time,  in  proportion  as  the  limb  shall  have  been  more 
or  less  disturbed. 

In  the  fracture  of  the  fibula  only,  the  position  is  not  of  much 
consequence;  because,  by  the  tibia  remaining  entire,  the  figure  of 
the  leg  is  preserved,  and  extension  quite  unnecessary;  but  still, 
even  here,  the  laying  the  leg  on  its  side,  instead  of  on  the  calf, 
is  attended  with  one  very  good  consequence;  viz.  that  the  confine- 
ment of  the  knee,  in  a  moderately  bent  position,  does  not  render 
it  so  incapable  of  flexion  and  use  afterward,  as  the  straight  or  ex- 
tended position  of  it  does;  and  consequently  that  the  patient  will 
be  much  sooner  able  to  walk,  whose  leg  has  been  kept  in  the  for- 
mer posture,  than  he  whose  leg  has  been  confined  in  the  latter. 

In  the  fracture  of  both  tibia  and  fibula,  the  knee  should  be  mo- 
derately bent,  the  thigh,  body,  and  leg,  in  the  same  position  as  in 
the  broken  thigh.  If  common  splints  be  used,  one  should  be 
placed  underneath  the  leg,  extending  from  above  the  knee  to 
below  the  ancle,  the  foot  being  properly  supported  by  pillows, 
bolsters,  &c.;  and  another  splint  of  the  same  length  showld  be 
placed  on  the  upper  side,  comprehending  both  joints  in  the  same 
manner;  which  disposition  of  splints  ought  always  to  be  observed^ 
as  to  their  length,  if  the  leg  be  laid  extended  in  the  common-way, 
only  changing  the  nominal  position  of  them,  as  the  posture  of 
the  leg  is  changed,  and  calling  what  is  inferior  in  one  case,  ex- 
terior in  the  other;  and  what  is  superior  in  one,  in  the  other  in- 
ferior.'^ 

t  All  writers  on  this  subject  agree  in  giving  iis  cautions  about  defending 
the  heel,  and  filling  up  the  hollow  from  it  to  the  calf  of  the  leg;   and  this 
they  do  on  account  of  the  pain,  excoriation,  and  even  ulceration,  which 
sometimes  attend  the  straight  position,  with  the  Umb  resting  on  the  heel. 
.  Many  of  them  have  also  taken  notice  of  an  accident  sometimes  attendant 


AND  DISLOCATIONS.  343 

If  Mr.  Sharpe's  splints  be  made  use  of,  there  is  in  one  of  them 
a  provision  for  the  more  easy  support  of  the  foot  and  ancle,  by  an 
excavation  in,  and  a  prolongation  of  the  lower  or  fibular  splint, 
for  the  purpose  of  keeping  the  foot  steady. 

I  hope  that  I  have  expressed  my  meaning  clearly;  I  should  be 
very  sorry  to  be  mistaken,  because  it  appears  to  me  to  be  a  matter 
of  some  consequence;  and  if  what  I  have  said  be  intelligible,  the 
reader  will  understand  from  thence,  that  I  mean  to  signify  that 
(in  my  opinion)  extension  will  in  general  be  made  with  more 
facility,  and  coaptation  more  happily  executed;  that  a  patient  will 
suffer  a  great  deal  less  pain  during  these  operations,  as  well  as 
during  the  necessary  confinement  for  a  broken  leg  or  thigh;  and 
that  both  patient  and  surgeon  will  be  less  likely  to  be  disappoint- 
ed in  their  intention  and  wish;  that  is,  that  the  former  will  be  less 
liable  to  lameness  or  deformity,  when  a  fractured  thigh  or  leg  has 
been  treated  in  the  way  I  have  described,  than  in  the  common 
one. 

The  resistance  necessarily  made  by  the  muscles,  joined  to  the 
great  instability  of  parts  in  every  species  of  fractured  leg  or  thigh, 
except  in  the  few  where  the  bones  are  broken  transversely,  has 
constantly  exercised  the  invention  and  ingenuity  of  practitioners, 
in  devising  means  to  prevent  inequality  in  the  callus,  as  it  is  called, 
and  shortness  and  deformity  of  the  limb.  Our  books  abound 
with  draughts  and  descriptions  of  machines  for  this  purpose;  liga- 
tures, pullies,  leaden  weights,  and  fracture- boxes,  so  constructed 
as  to  overcome  and  constantly  to  resist  that  action  of  the  muscles 
surrounding  the  broken  bone,  that  natural  tendency  in  them  to 
contract,  which  the  extended  position  of  the  limb  necessarily  in- 
duces. Every  body  who  has  been  conversant  wiih  matters  of 
this  sort  knows,  that  even  the  best  of  these  various  contrivances 
often  prove  successless;  and  every  one  who  will  reflect  ever  so 
little  may  see  why  they  must  be  so.  That  they  do  prove 
ineffectual,  the  number  of  deformed  legs  and  shortened  thighs, 
which  are  daily  met  with,  evinces;  and  that  they  must  frequently 

on  a  broken  leg,  but  which  really  ought  to  be  set  to  the  accovxnt  of  the  pes- 
ture  in  which  such  a  leg  is  placed,  more  than  to  tiiat  of  the  fracture  :  I  mean 
the  shrinking  or  wasting  of  the  calf. 


244  REMARKS  ON  FRACTURES 

prove  so  will  be  obvious  to  every  one,  who  will  consider  that  the 
effect  can  last  no  longer  than  the  cause  is  continued,  unless  there 
happens  to  be  some  very  favourable  circumstance  in  the  fracture 
itself.  What  I  mean  is  this,  when  the  reduction  of  the  fracture 
is  set  about,  the  limb  is  put  into  such  position,  that  the  surround- 
ing muscles  resist  the  extending  force  very  considerably,  and  this 
in  proportion  to  their  strength  and  number;  that  force  is  continued 
and  increased  till  the  muscles  give  way;  and  the  resistance  being 
overcome,  an  opportunity  is  thereby  obtained  of  placing  the  ends 
of  the  fracture  in  as  apt  position  with  regard  to  each  other  as  the 
nature  of  it  will  admit.  If  the  fracture  be  of  the  transverse  kind; 
that  is,  if  the  ends  of  the  broken  bone  be  large,  and  afford  a  good 
deal  of  space  for  contact  with  each  other,  such  apposition  will 
contribute  a  good  deal  to  the  keeping  the  limb  steady,  and  the  frac- 
ture even;  but  if  the  fracture  be  of  the  oblique  kind,  if  there  be 
several  loose  pieces,  and  consequently  neither  large  contact  nor 
stability  from  the  apposition,  or  if  due  extension  has  not  been  made^ 
or  could  not,  or  if  the  ends  of  the  bones  have  not  been  judiciously 
and  properly  set,  the  muscles  will  act  as  soon  as  the  extension  is 
relaxed,  the  fracture  will  be  more  or  less  displaced,  according  to 
the  nature  of  it,  the  limb  will  be  shortened,  the  time  of  union  will 
be  prolonged,  and  the  place  of  it  (the  callus,  as  it  is  called)  will 
be  in  proportion  more  or  less  unequal. 

I  take  it  for  granted  that  it  will  be  asked,  Have  not  our  ances- 
tors in  all  times  happily  redressed  fractured  legs  and  thighs,  by 
the  method  which  they  have  delivered  down  to  us,  and  which  in 
the  preceding  pages  I  have  taken  the  liberty  to  object  to?  Have 
not  such  limbs  frequently  been  rendered  as  straight,  as  useful,  and 
as  little  deformed  as  possible?  I  answer,  most  certainly,  yes;  it 
is  an  undoubted  truth,  and  cannot  be  denied.  But  in  my  turn,  let 
me  be  permitted  to  ask,  whether  in  the  same  method  great  and 
even  unsurmountable  difficulty  is  not  frequently  met  with?  Whe- 
ther in  many  cases  the  act  of  setting,  as  it  is  called,  is  not  exces- 
sively painful  at  the  time,  and  productive  of  inflammation  and  other 
disagreeable  symptoms  afterward?  and  whether,  in  spite  of  all 
care,  of  every  contrivance,  of  every  species  of  machinery  which 
has  yet  been  used,  broken  thighs  and  legs  are  not  often,  very 


AND  DISLOCATIONS.  24^5 

often,  left  deformed,  crooked,  and  shortened,  and  that  merely  from 
the  aciion  of  the  muscles,  and  the  obliquity  or  shattered  state  of 
the  fracture?  The  fact  is  notorious,  and  the  sole  question  is, 
whether  or  no  a  different  disposition  of  the  parts  preventing  such 
action  and  such  resistance,  will  in  many  instances  prevent  these 
evils?  To  which,  from  repeated  experience,  I  answer,  Yes.  If 
this  should  be  found  to  be  the  case  in  general,  of  which  I  make 
no  doubt  that  it  is;  if  by  this  method,  many  of  such  unfortunate 
cases,  as  in  the  common  method  of  treatment,  disappoint  both- 
patient  and  surgeon,  should  be  found  in  general  to  succeed  so  well 
as  to  satisfy  both,  it  will  prove  all  I  wish  it  should  prove.  Su- 
perior utility  and  more  frequent  success  are  all  I  contend  for. 

Many  people  did  very  well  under  amputation  before  the  double 
incision  was  practised;  but  is  the  double  incision  therefore  no 
improvement?  The  operation  for  the  bubonocele  may  be  per- 
formed with  that  clumsy  instrument  the  probe  scissors,  but  is  the 
bistoury  therefore  not  preferable?  A  surgeon  may  cut  off  some 
ounces,  or  even  pounds  of  flesh  from  a  patient's  backside,  in 
order  to  care  a  sinus,  but  is  the  cure  by  the  simple  division  of 
that  sinus  therefore  not  easier  or  more  expeditious?  Neither  of 
these  can  (I  think)  be  proved,  unless  it  can  at  the  same  time  be 
proved,  that  pain  is  no  evil,  confinement  not  at  all  irksome,  and 
that  deformity  and  elegance  of  figure  are  synonymous  terms. 

Let  not  the  reader  fancy  that  I  would  dare  to  amuse  him  with 
speculation,  or  merely  specious  reasoning  on  a  subject  like  this. 
What  I  have  said  is  from  experience,  repeated  experience  both 
of  myself  and  of  others,  for  a  considerable  length  of  time  past, 
and  on  a  great  variety  of  subjects;  from  an  experience  which  has 
perfectly  satisfied  me,  and  I  think  will  every  man  who  will  make 
the  trial  fairly  and  candidly.  I  do  not  pretend  to  say,  that  by 
these  means  every  kind  of  broken  bone  will  infallibly  and  cer- 
tainly be  brought  to  lie  smooth,  even,  and  of  proper  length;  if  I 
did,  they  who  are  versed  in  these  things  would  know  that  I  said 
too  much:  but  I  will  say,  (what  is  sufficient  for  my  purpose,)  that 
it  will  not  only  succeed  in  all  those,  in  which  the  old  method 
can  ever  be  successful;  but  also  in  the  majority  of  those  in  which 
it  is  not,  nor  in  the  nature  of  things  can.  Jn  those  fortunate 
c^ses,  in  which  either  method  will  do,  the  old  one  is  fatiguing, 


346  REMARKS  ON  FRACTURES 

inconvenient,  and  even  sometimes  offensive,  from  the  supine  and 
confined  posture  of  the  patient;  whereas,  that  which  is  here  pro- 
posed, gives  the  patient  much  greater  liberty  of  motion  for  every 
purpose  either  of  choice  or  necessity;  and  in  many  of  those  cases, 
wherein  the  old  method  proves  most  frequently  so  far  success- 
less, as  to  leave  the  limb  short,  lame,  or  deformed,  I  say,  in  most 
of  these,  the  proposed  method  will  not  be  attended  with  these  in- 
conveniencies. 

I  have  already  said,  that  in  most  cases  of  broken  thigh  or  leg, 
the  method  just  described  will  be  attended  with  great  success: 
but  there  is  one  particular  case  in  which  its  utility  is  still  more 
conspicuous;  a  case  which,  according  to  the  general  manner  of 
treating  it,  gives  infinite  pain  and  trouble  both  to  the  patient  and 
surgeon,  and  very  frequently  ends  in  the  lameness  and  disappoint- 
ment of  the  former,  and  the  disgrace  and  concern  of  the  latter — I 
mean  the  fracture  of  the  fibula  attended  with  a  dislocation  of  the 
tibia. 

Whoever  will  take  a  view  of  the  leg  of  a  skeleton,  will  see  that 
although  the  fibula  be  a  very  small  and  slender  bone,-  and  very 
inconsiderable  in  strength,  when  compared  with  the  tibia,  yet  the 
support  of  the  lower  joint  of  that  limb  (the  ancle)  depends  so  much 
on  this  slender  bone,  that  without  it  the  body  would  not  be  upheld, 
nor  locomotion  performed,  without  hazard  of  dislocation  every 
moment.  The  lower  extremity  of  this  bone,  which  descends  con- 
siderably below  that  end  of  the  tibia,  is  by  strong  and  inelastic 
ligaments  firmly  connected  with  the  last-named  bone,  and  with 
the  astragalus,  or  that  bone  of  the  tarsus  which  is  principally  con- 
cerned in  forming  the  joint  of  the  ancle.  This  lower  extremity 
of  the  fibula  has,  in  its  posterior  part,  a  superficial  sulcus  for  the 
lodgement  and  passage  of  the  tendons  of  the  peronei  muscles,  which 
are  here  tied  down  by  strong  ligamentous  capsula;,  and  have  their 
action  so  determined  fiom  this  point  or  angle,  that  the  smallest 
degree  of  variation  from  it,  in  consequence  of  external  force,  must 
necessarily  have  consideiable  etfect  on  the  motions  they  are  de- 
signed to  execute,  and  consequently  distort  the  foot.  Let  it  also 
be  considered,  that  upon  he  due  and  natural  state  of  the  joint 
of  the  ancle,  that  is,  upon  the  exact  and  proper  disposition  of  the 
tibia  and  fibula,  both  with  regard  to  each  qther  and  to  the  astra- 


^h>/i/  ycxTyf  S!t7.  Vol.  J  . 


^^j:*JJ>//y,'/ur   S.'. 


AND  DISLOCATIONS.  247 

galus,  depend  the  just  disposition  and  proper  action  of  several 
other  muscles  of  the  foot  and  toes;  such  as  the  gastrocnemii,  the 
tibialis  anticus  and  posticus,  the  flexor  pollicis  longus,  and  the 
flexor  digitorum  pedis  longus,  as  must  appear  demonstrably  to 
anj  man  who  will  first  dissect,  and  then  attentively  consider  these 
parts. 

If  the  tibia  and  fibula  be  both  broken,  they  are  both  generally 
displaced  in  such  manner,  that  the  inferior  extremity,  or  that 
connected  with  the  foot,  is  drawn  under  that  part  of  the  fractured 
bone  which  is  connected  with  the  knee;  making  by  this  means  a 
deformed,  unequal  tumefaction  in  the  fractured  part,  and  render- 
ing the  broken  limb  shorter  than  it  ought  to  be,  or  than  its  fellow. 
And  this  is  generally  the  case,  let  the  fracture  be  in  what  part  of 
the  leg  it  may. 

If  the  tibia  only  be  broken,  and  no  act  of  violence,  indiscretion, 
or  inadvertence  be  committed,  either  on  the  part  of  the  patient  or 
©f  those  who  conduct  him,  the  limb  most  commonly  preserves  its 
figure  and  length;  the  same  thing  generally  happens  if  the  fibula 
only  be  broken,  in  all  that  part  of  it  which  is  superior  to  letter  .^  in 
the  annexed  figure,  or  in  any  part  of  it  between  its  upper  extre- 
mity, and  within  two  or  three  inches  of  its  lower  one. 

I  have  already  said,  and  it  will  obviously  appear  to  every  one 
who  examines  it,  that  the  support  of  the  body,  and  the  due  and 
proper  use  and  execution  of  the  office  of  the  joint  of  the  ancle, 
depend  almost  entirely  on  the  perpendicular  bearing  of  the  tibia 
upon  the  astragalus,  and  on  its  firm  connexion  with  the  fibula.  If 
either  of  these  be  perverted  or  prevented,  so  that  the  former  bone 
is  forced  from  its  just  and  perpendicular  position  on  the  astraga- 
lus; or  if  it  be  separated  by  violence  from  its  connexion  with  the 
latter,  the  joint  of  the  ancle  \xi\\  suffer  a  partial  dislocation  in- 
ternally;'' which  partial  dislocation  cannot  happen  without  not  only 
a  considerable  extension,  or  perhaps  laceration  of  the  bursal  liga- 
ment of  the  joint,  which  is  lax  and  weak,  but  a  laceration  of  those 
strong  tendinous  ligaments,  which  connect  the  lower  end  of  the 
tibia  with  the  astragalus  and  os  calcis,  and  which  constitute  in 
great  measure  the  ligamentous  strength  of  the  joint  of  the  ancle. 

"  See  the  figure  at  the  preceding  page. 


348  REMARKS  ON  FRACTURES 

This  is  the  case,  when,  by  leaping  or  jumping,  the  fibula  breaks 
in  the  weak  part  already  mentioned;  that  is,  within  two  or  three 
inches  of  its  lower  extremity.  When  this  happens,  the  inferior 
fractured  end  of  the  fibula  falls  inward  toward  the  tibia,  that  ex- 
tremity of  the  bone  which  forms  the  outer  ancle  is  turned  some- 
what outward  and  upward,  and  the  tibia  having  lost  its  proper 
support,  and  not  being  of  itself  capable  of  steadily  preserving  its 
true  perpendicular  bearing,  is  forced  off  from  the  astragalus  in- 
wards, by  which  means  the  weak  bursal,  or  common  ligament  of 
the  joint,  is  violently  stretched,  if  not  torn,  and  the  strong  ones^ 
which  fasten  the  tibia  to  the  astragalus  and  os  calcis,  are  always 
lacerated;  thus  producing  at  the  same  time  a  perfect  fracture  and 
a  partial  dislocation,  to  which  is  sometimes  added  a  wound  in  the 
integuments,  made  by  the  bone  at  the  inner  ancle.  By  this  means, 
and  indeed  as  a  necessary  consequence,  all  the  tendons  which  pass 
behind  or  under,  or  are  attached  to  the  extremities  of  the  tibia  and 
fibula,  or  os  calcis,  have  their  natural  direction  and  disposition  so 
altered,  that,  instead  of  performing  their  appointed  actions,  they 
all  contribute  to  the  distortion  of  the  foot,  and  that  by  turning  it 
outward  and  upward. 

When  this  accident  is  accompanied,  as  it  sometimes  is,  with  a 
wound  of  the  integuments  of  the  inner  ancle,  and  that  made  by  the 
protrusion  of  the  bone,  it  not  infrequently  ends  in  a  fatal  gan- 
grene, unless  prevented  by  timely  amputation,  though  I  have  se- 
veral times  seen  it  do  very  well  without.  But  in  its  most  simple 
state,  unaccompanied  with  any  wound,  it  is  extremely  troublesome 
to  put  to  rights,  still  more  so  to  keep  it  in  order,  and  unless  ma- 
naged with  address  and  skill,  is  very  frequently  productive  both 
of  lameness  and  deformity  ever  after. 

After  what  has  been  said,  a  further  explanation  why  this  is  so 
is  unnecessary.  Whoever  will  take  even  a  cursory  view  of  the 
disposition  of  the  parts,  will  see  that  it  must  be  so.  By  the  frac- 
ture of  the  fibula,  the  dilatation  of  the  bursal  ligament  of  the  joint, 
and  the  rupture  of  those  which  should  tie  the  end  of  the  tibia 
firmly  to  the  astragalus  and  os  calcis,  the  perpendicular  bearing  of 
the  tibia  on  the  astragalus  is  lost,  and  the  foot  becomes  distorted; 
by  this  distortion,  the  direction  and  action  of  all  the  muscles  al- 
ready recited  are  so  altered,  that  it  becomes  (in  the  usual  way  of 


AND  DISLOCATIONS.  249 

treating  this  case)  a  difficult  matter  to  reduce  the  joint,  and,  the 
support  of  the  fibula  being  gone,  a  more  difficult  one  to  keep  it  in 
its  place  after  reduction.  If  it  be  attempted  with  compress  and 
strict  bandage,  the  consequence  often  is  a  very  troublesome,  as 
well  as  painful  ulceration  of  the  inner  ancle,  which  very  ulcera- 
tion becomes  itself  a  reason  why  such  kind  of  pressure  and  band- 
age can  be  no  longer  continued;  and  if  the  bone  be  not  kept  in  its 
place,  the  lameness  and  deformity  are  such,  as  to  be  very  fatiguing 
to  the  patient,  and  to  oblige  him  to  wear  a  shoe  with  an  iron,  or 
a  laced  buskin,  or  something  of  that  sort,  for  a  great  while,  or 
perhaps  for  life. 

All  this  trouble,  pain,  difficulty,  and  inconvenience,  are  oc- 
casioned by  putting  and  keeping  the  limb  in  such  position  as 
necessarily  puts  the  muscles  into  action,  or  into  a  state  of  resist- 
ance, which  in  this  case  is  the  same.  This  occasions  the  diffi- 
culty in  reduction,  and  the  difficulty  in  keeping  it  reduced;  this 
distorts  the  foot,  and  by  pulling  it  outward  and  upward  makes 
that  deformity  which  always  accompanies  such  accident:  but  if 
the  position  of  the  limb  be  changed,  if,  by  laying  it  on  its  outside, 
with  the  knee  moderately  bent,  the  muscles  forming  the  calf  of 
the  leg,  and  those  which  pass  behind  the  fibula  and  under  the  os 
calcis  are  all  put  into  a  state  of  relaxation  and  non-resistance, 
all  this  difficulty  and  trouble  do  in  general  vanish  immediately; 
the  foot  may  easily  be  placed  right,  the  joint  reduced,  and  by 
maintaining  the  same  disposition  of  the  limb,  every  thing  will  in 
general  succeed  very  happily,  as  I  have  many  times  experienced. 

Two  kinds  of  fracture  there  are,  and  only  two  that  I  can  recol- 
lect (relative  to  the  limbs)  which  do  not  admit  of  the  bent  posi- 
tion of  the  joints;  I  mean  that  of  the  processus  olecranon  at  the 
elbow,  and  that  of  the  patella:  in  these  a  straight  position  of  the 
arm  and  leg  is  necessary;  in  the  former  to  keep  the  fractured 
parts  in  contact  till  they  are  united;  in  the  latter,  to  bring  them 
as  near  to  each  other  as  may  best  serve  the  purpose  of  walking 
afterward.' 

With  regard  to  the  fracture  of  the  patella,  an  opinion  has  long 

» Although  a  straight  position  of  the  limb  Is  necessary  for  the  broken  pa- 
tella, yet  this  very  position  becomes  so  upon  the  same  principle,  as  renders 
VOL.  I.  I  i 


250  REMARKS  ON  FRACTURES 

and  generally  prevailed,  which  seems  to  me  to  have  no  foundtt- 
tion  in  truth,  or  (when  duly  considered)  even  in  probability;  it  is, 
that  the  great  degree  of  stiffness  in  the  joint  of  the  knee,  which 
is  sometimes  found  to  be  the  consequence  of  this  kind  of  fracture, 
is  owing  to,  or  produced  by,  a  quantity  of  callus  falling  into  it 
from  the  edges  of  the  broken  bone;  and  that  the  nearer  tire  broken 
pieces  are  brought  to  each  other,  the,  more  likely  such  conse- 
quence is. 

Every  part  of  this  doctrine  seems  equally  absurd.  Jn  the  first 
place,  the  fractured  bone  is  by  no  means  capable  of  supplying 
such  a  quantity  of  callus  as  to  produce  this  end,  unless  it  may  be 
supposed  to  run  from  it  as  solder  from  a  plumber's  ladle;  in  the 
second  place,  if  this  was  the  case,  the  most  likely  and  indeed  the 
only  probable  way  of  preventing  the  deposition  of  such  juice, 
must  be  by  bringing  the  broken  pieces  into  close  contact;  and  in 
the  third  place,  there  is  no  authority,  from  the  appearance  of  such 
joints  after  death,  (at  least  as  far  as  my  experience  goes,)  to  sup- 
pose this  to  be  the  case,  or  to  countenance  such  opinion.  The 
cause  therefore  of  this  rigidity,  which  is  now  and  then  found  to 
attend  the  broken  patella,  must  be  sought  for  elsewhere;  vis.  in 
the  long  rest  and  confinement  of  the  joint  as  a  means  used  by 
many  to  procure  exact  union;  in  mischief  done  to  the  ligament, 
which  is  formed  by  the  united  tendons  of  the  four  extensor  mus- 
cles of  the  leg,  at  the  time  of  and  by  the  fracture;  and  in  the  na- 

the  bent  posture  most  advantageous  in  the  broken  tibia  and  femur;  viz.  the 
relaxation  of  the  muscles  and  tendons  attached  to  the  fractured  bone. 

Whoever  will  for  a  moment  attend  to  the  disposition  of  the  pieces  in  a  pa- 
tella, which  has  been  broken  transversely,  will  see  how  little"  necessary  or 
useful  the  many  contrivances  of  bandages,  straps,  compresses,  buckles,  but- 
tons, &c.  to  be  found  in  writers  are,  especially  all  that  part  of  them  which  are 
applied  to  the  inferior  fragment. 

By  the  action  of  the  united  tendons  of  the  extensores  muscles  of  the  leg, 
the  superior  fragment  is  pulled  upward  and  separated  from  the  inferior,  but 
the  latter  remains  nearly,  if  not  absolutely,  where  it  was  before  the  accident; 
there  is  nothing  to  act  upon  it,  and  therefore  it  cannot,  nor  does  it  move. 

The  extension  of  the  leg  puts  the  muscles  attached  to  the  upper  part  of 
the  broken  bone  into  a  state  of  relaxation,  and  prevents  their  acting ;  and 
though  a  small  compress  just  above  this  piece,  with  a  moderate  bandage,  may 
be  useful  toward  retaining  it,  yet  it  is  the  position  of  the  leg  which  mu^ 
keep  the  broken  piece  down,  and  effect  the  cure. 


AND  DISLOCATIONS.  251 

ture  of  the  fracture  itself,  that  is,  the  manner  in  which  the  bone 
shall  happen  to  be  broken. 

But,  be  all  this  as  it  may,  the  fact  undoubtedly  is,  that  they 
walk  best  after  such  accident,  whose  patella  has  been  broken 
transversely,  and  that  into  two  nearly  equal  fragments;  whose  con- 
finement to  the  bed  has  been  short,  that  is,  no  longer  than  while 
the  inflammation  lasted;  whose  knee,  after  such  period,  has  been 
daily  and  moderately  moved;  and  in  whom  the  broken  pieces  are 
not  brought  into  exact  contact,  but  lie  at  some  small  distance  from 
,  each  other.' 

'  It  has  been  sutjgestecl  to  me  that  there  is  an  obscurity  in  this  passage^  and 
that  Mr.  Potl's  doctrine  wllli  regard  to  the  fractured  patella  is  not  clearly 
understood;  in  consequence  of  vvliich,  his  authority  has  been  quoted  for 
giving  motion  to  the  joint  soon  after  the  accident,  and  for  keepingthe  divid- 
ed parts  of  the  patella  separate  from  each  other  to  a  great  distance. 
Whoever  has  conceived  this  to  be  Mr.  Pott's  meanings  has  certainly  been 
mistaken,  as  his  practice  differed  very  materially  from  it.  As  the  passage 
inenlions,  that  the  confinetnent  need  not  be  longer  than  while  the  inflamma- 
tion lasts,  the  time  which  is  proposed  to  keep  the  limb  quiet  after  the  acci- 
dent  is  perhaps  not  sufficiently  definite,  nor  expressed  with  Mr.  Pott's  usual 
precision,  as  frequently  only  a  small  degree  of  inflammation  is  excited,  par- 
ticularly in  those  cases  where  the  knee  does  not  reach  the  ground,  which 
often  happens.  Every  one  conversant  in  business  must  have  seen  instances 
of  this  fact,  where  the  bone  is  torn  asunder  by  the  mere  force  of  the  exten- 
sor muscles:  it  has  happened  to  a  person  standing  firm,  and  reaching  for 
something  on  a  higli  shelf,  by  which  posture  those  muscles  are  put  into 
strong  action,  as  must  be  evident  to  any  one  who  will  make  the  experiment; 
in  these  cases  there  is  no  external  injury,  and  frequently  little  inflammation 
follows  the  fracture.  Are  we  then  imijiediately  to  move  the  limb,  and  keep 
the  parts  of  the  bone  separate.'  Certainly  not.  Mr.  Pott  only  meant  to 
caution  against  too  strict  and  too  long  confinement;  and  his  constant  practice 
was,  to  lay  the  leg  in  a  perfectly  straight  posture,  to  elevate  the  heel,  and, 
by  a  moderate  bandage  and  compress,  to  bring  down  the  superior  portion  of 
the  patella.  In  this  position  he  usually  kept  it  near  thi'ee  weeks,  after 
which  time  he  allowed  of  a  small  degree  of  motion,  which  he  recommended 
to  be  gradually  increased. 

In  fractures  of  this  bone,  it  is  not  always  in  our  power  to  bring  the  divided 
parts  into  contact,  consequently  there  will  be  a  space,  which  will  be  supplied 
with  ligamentous  substance,  as  the  osseous  fibres  are  here  sparingly  produced. 
In  proportion  to  the  distance  between  the  two  parts  of  the  bone,  the  chord  or 
tendon  on  which  the  extensor  muscles  act,  must  be  longer  than  when  the  bone 
is  in  its  perfect  state,  and  the  muscular  power  must  be  propt)rtionally  lessen- 
ed.   This  should  certainly  be  avoided  as  much  as  possible,  and  can  only  be 


;262  REMARKS  ON  FRACTURES 

1  cannot  take  leave  of  this  subject  of  simple  fractures,  without 
nieptioning  a  circumstance  relative  to  them,  which  although, 
when  rightly  understood,  is  of  little  or  no  importance,  yet,  by 
being  misunderstood,  becomes  frequently  of  considerable  conse- 
quence. 

I  mean,  the  use  of  the  term,  rising  end  of  a  broken  bone. 

By  the  expression,  any  one  unacquainted  with  these  things 
would  be  inclined  to  think,  that  the  prominent  part  of  a  broken 
bone  rose,  or  was  elevated  from  its  natural  place;  and  became  by 
such  rising  superior  to  the  other  part  or  extremity  of  the  fracture. 
This  would  certainly  be  the  idea  of  an  ignorant  person,  and  as 
such  would  be  of  liltle  consequence;  but  by  the  practice  of  many, 
who  call  themselves  surgeons,  it  is  as  certainly  their  idea  also, 
and  this  renders  it  a  matter  of  great  consequence.  Many  in- 
stances are  producible,  in  which  our  conduct  is  in  great  measure 
regulated  by  the  language  which  we  use.  Having  no  ideas  annexed 
to  our  words,  leads  us  into  absurdity  and  unintelligibility;  but 
false  ones  influence  us  still  more,  and  frequently  produce  very  ma- 
terial errors. 

The  fistula  lachrymalis,  the  fistula  in  perineo,  and  that  in  ano, 
are  glaring  proofs  of  this;  and  my  present  subject  is  full  as  much 
so:  for  upon  the  erroneous  idea  annexed  to  the  term  rising  end, 
stands  all  the  absurd  practice  of  compress,  bolster,  and  strict  ban- 
dage in  the  cases  of  simple  fracture.u 

avoided  by  bringing  the  parts  as  nearly  as  may  be  into  contact.  Unless  this 
union  be  in  some  degree  preserved,  the  muscles  will  have  too  little  power 
on  the  ligament  which  is  inserted  in  the  tibia,  althouj'h  they  contract  to  the 
greatest  possible  degree;  consequently,  the  person,  whose  patella  is  much 
elongated,  is  obliged  to  depend  principally  on  the  flexor  muscles  of  the  thigh 
and  the  weight  of  the  leg  itself,  to  bring  it  forward  in  progressioti,  which  is 
performed  in  a  most  awkward  manner,  and  is  found  pai-ticularly  inconvenient 
in  going  up  and  down  stairs.  If  both  patelisc  have  been  broken,  and  are  in 
the  same  lengthened  state,  the  person  is  generally  obliged  to  ascend  and 
descend  sideways.    E. 

"  I  was  some  few  years  ago  carried  by  a  surgeon,  since  dead,  to  see  a  con- 
trivance of  his  own  to  keep  down  the  rising  end  of  a  broken  tibia.  It  was 
somewhat  upon  the  principle  of  Petit's  tourniquet,  and  calculated  to  act  by 
compression.  I  told  him  my  opinion  freely,  but  the  inventor  was  wedded  to 
his  invention;  and  the  first  simple  fracture  he  applied  it  to  he  thereby  con- 
verted into  a  compound  one,  by  pressing  the  bone  through  the  skin. 


AND  DISLOCATIONS.  253 

The  truth  is,  that  there  is  really  no  rising  end  to  a  broken  bone; 
I  mean,  when  applied,  as  the  term  usually  is,  to  the  leg,  thigh,  and 
clavicle.  There  is  indeed  a  superior  or  prominent  end  or  part, 
and  an  inferior  or  depressed  one;  but  the  former  of  these  is  in  its 
proper  place,  from  which  it  cannot  by  art  be  moved;  and  the 
latter,  which  is  not  in  its  proper  place,  is  very  capable  by  art  of 
being  put  into  it. 

Perhaps  this  may  to  some  appear  a  mere  play  of  words,  a 
nominal  distinction,  without  real  difference;  but  when  the  influence 
which  a  right  or  wrong  idea  of  this  produces  on  practice  is  attend- 
ed to,  the  consequence  will  be  obvious  and  serious. 

When  a  collar  bone,  os  femoris,  or  tibia  and  fibula  are  broken, 
by  the  action  of  the  muscles,  by  the  motions  of  the  patient,  and  by 
the  mere  weight  of  the  inferior  part  of  the  arm,  thigh,  or  leg,  the 
fractured  ends  of  such  bones  are  displaced,  and  always  displaced 
in  such  manner,  that  the  inequality  occasioRed  necessarily  by  such 
displacement,  proceeds  from  the  inferior  end  of  the  fractured  bone 
being  retracted  or  drawn  under  the  superior:  this  produces  a 
tumefaction  or  unequal  rising;  and  the  upper  extremity  of  the 
fracture  is  therefore  called  the  rising  end  of  it.  Now  the  man 
who  regards  this  rising  end  as  that  part  of  the  fracture  which  has 
by  such  rising  got  out  of  its  place,  and  not  as  having  accidentally 
become  the  prominent  part  merely  by  the  insinuation  or  retraction 
of  the  other  part  underneath  it,  will  go  to  work  with  bolster, 
compress,  and  bandage,  in  order  to  bring  and  keep  such  end 
down;  by  which  means  he  will  give  his  patient  considerable  pain, 
and,  while  he  depends  on  such  means  alone,  will  most  certainly 
be  frustrated  in  his  intention  and  expectation,  the  means  not 
being  adequate  to  the  proposed  end.  But  the  man  who  looks  on 
this  in  the  true  light,  that  is,  who  looks  on  the  superior  part  as 
being  in  its  proper  place,  and  the  inferior  as  being  displaced  by 
the  weight  of  the  limb  and  the  action  of  the  muscles,  will  know, 
that,  by  the  mere  position  of  such  limb,  he  shall  be  able  to  remedy 
all  the  inconvenience  and  deformity,  as  far  as  they  are  by  art 
capable  of  remedy,  without  the  parade  or  the  fatigue  of  useless 
apparatus. 

He  will,  for  example,  know  that  the  prominent  part  of  a  bro- 
ken clavicle,  that  part  of  it  which  is  next  to  the  sternum,  is  just 


2M  REMARKS  ON  FRACTURES 

where  it  should  be;  and  that  the  inferior  part,  that  which  is  con- 
nected with  the  scapula,  is  out  of  its  place,  by  being  drawn  down 
by  the  weight  of  the  arm;  and,  therefore,  instead  of  loading,  as  is 
usual,  the  prominent  part  with  quantities  of  compress,  which 
never  can  do  any  service,  he,  by  a  proper  elevation  of  the  arm, 
will  bring  the  lower  end  upward  into  contact  with  the  other;  and 
thereby,  with  very  little  trouble,  easily  accomplish  what  he  never 
can  do  in  any  other  manner,  however  operose. 

The  same  thing  will  happen,  from  the  same  principles,  in  the 
leg  and  thigh:  a  prominence,  or  a  rising  end,  there  always  will 
be;  but  that  rising  end  is  never  to  be  brought  down  by  any  press- 
ure from  compress  or  bandage:  the  fallen  or  inferior  one  must 
always  be  brought  up  to  it  by  the  proper  position  of  the  rest  of 
the  limb:  this  will  always  remove  the  inequality  as  far  as  it  is  re- 
moveable,  and  nothing  else  can." 

s  In  a  professed  regular  treatise  on  this  subject,  it  would  be  right  to  take 
notice  of  what  may  be  called  the  infortunia  or  accidental  evils,  which  some- 
times accompany  even  simple  fractures ;  such  are,  disease  arising  from  in- 
jury done  to  the  medullary  membrane,  within  the  bones,  in  bad  habits  ;  he- 
morrhage, or  a  species  of  spurious  aneurism,  from  a  wound  of  the  interoseal 
artery,  between  tlie  tibia  and  fibula,  or  of  either  of  the  carpal  ai-teries;  mis- 
chief from  the  fracture  becoming  accidentally  the  seat  of  the  crisis  of  a  fe- 
ver; deficiency  of  callus,  or  the  accident  of  the  broken  bone  not  uniting;  the 
ft-actured  limb  becoming  the  seat  of  an  erysipelas,  terminating  in  a  slough  of 
the  common  membrane  and  periosteum  ;  the  gelatinous  juice  or  callus,  which 
should  unite  the  fracture,  being  in  so  morbid  a  state  as  to  produce  a  kind  of 
caries  with  exostosis,  instead  of  doing  its  proper  duty,  &c.  Of  all  these  there 
are  examples,  but  they  do  not  come  within  the  plan  which  I  prescribed  to 
myself  when  I  began  these  papers. 


AND  DISLOCATIONS.  25fi 


\*  Mr.  Pott  might  undoubtedly  have  been  more  diffuise,  and 
have  considerably  dilated  on  his  subject,  if  he  had  taken  into  con- 
sideration the  various  incidents  which  he  has  enumerated  in  the 
preceding  note;  and  which  are  sometimes  the  consequences  of 
fractured  bones:  but  though  (as  he  observes)  this  may  not  be 
deemed  a  professed  regular  treatise,  he  has  certainly  undervalued 
it,  when  he  entitled  it  "  A  few  general  Remarks  on  Fractures  and 
Dislocations,"  as  the  reader  must  have  observed  that  it  abounds 
in  observations  and  rules  of  great  consequence  on  this  very  im- 
portant subject.  Andj  indeed,  it  has  been  the  principal  cause  of 
introducing  a  new  mode  of  treating  fractures,  which  is  now  almost 
universally  approved  and  adopted.  The  idea  of  relaxing  the  mus- 
cles, in  order  more  easily  to  set  a  broken  or  dislocated  limb,  is  of 
infinite  importance;  and  was  certainly  not  sufficiently  attended  to 
before  this  treatise  made  its  appearance. 

If  it  were  necessary  to  add  any  thing  to  the  advantages  which 
Mr.  Pott  has  mentioned  arising  from  the  relaxed  position  in  frac- 
tures, it  might  be  observed,  that  in  this  situation  patients  very 
rarely  suffer  from  cramps  and  spasms,  which  are  frequently  at- 
tendant when  the  limb  is  laid  straight,  and  are  extremely  painful 
and  productive  of  mischief;  and  I  might  add,  that  people,  whose 
limbs  have  been  fractured  by  a  fall,  a  kick  of  a  horse,  or  any 
other  accident,  are  very  subject  to  such  agitation  of  mind  that 
their  sleep  for  many  nights  is  unsound;  they  continually  dream  of 
what  they  have  suffered,  and  they  catch  and  spring  with  an  ima- 
ginary attempt  to  save  themselves.  When  the  leg  was  laid  in  a 
line  with  the  body,  the  jerk  was  infallibly  communicated  to  the 
fractured  part,  which  gave  the  patient  excruciating  pain,  and  de- 
stroyed his  repose  for  the  remainder  of  the  night;  and  in  the  morn- 
ing the  tedious  painful  process  of  putting  it  to  rights  was  neces- 
sarily renewed.  The  involuntary  actions  of  coughing. and  sneez- 
ing had  also  the  same  mischievous  effect;  and  whoever  has  seen 
fractured  legs  lying  in  the  straight  posture  must  be  sensible  that 
these  circumstances  have  frequently  occurred.  In  the  relaxed 
position  the  shock  is  lost  in  the  bended  joints  of  the  hip  and  knee, 
and  the  limb  is  not  obliged  to  move  with  the  body.  Yet,  although 


256  REftlARKS  ON  FRACTURES 

I  have  reason  to  approve  in  general  of  Mr.  Potl's  plan,  of  placing 
fractured  legs  on  the  outside,  on  the  fibula,  we  sometimes  find 
cases  which  should  form  exceptions  to  this  general  rule,  particu- 
larly in  fractures  of  the  leg,  where  the  broken  end  of  the  superior 
part  of  the  tibia  projects  forward.  In  that  case  we  sometimes 
find  it  impracticable  to  keep  the  ends  of  the  bone  even,  without 
placing  it  on  the  heel. 

In  compound  fractures,  also,  we  sometimes  find  great  advan- 
tage in  placing  the  leg  on  the  calf  and  heel;  for  instance,  where 
there  is  a  deep  wound  leading  down  to  the  bone  on  the  inside  of 
the  leg  or  ancle,  if  it  lies  on  the  outside  it  is  evident  that  a  cavity 
must  be  formed  in  which  the  matter  will  be  retained;  and  which, 
being  in  continual  contact  with  the  bones,  must  create  great  mis- 
chief, as  it  can  only  be  wiped  away,  and  that  very  imperfectly, 
once  or  twice  a  day,  when  the  wound  is  dressed.  In  this  case, 
sometimes  by  placing  the  leg  on  the  heel,  an  effectual  current  may 
be  given  to  the  matter,  so  soon  as  it  is  formed;  the  good  effect  of 
which  on  the  wound  will  soon  be  perceived.  In  short,  in  all  those 
cases  where  there  are  wounds,  in  which  a  depending  opening  can 
be  effected  by  the  position  on  the  heel,  it  is  to  be  preferred. 

Except  in  such  and  similar  cases  to  those  just  mentioned,  I  am 
a  strong  advocate  for  placing  brokenlegs  on  the  outside. 

But  I  must  confess  that  I  have  long  entertained  doubts  whether 
this  ought  to  be  considered  the  best  position  for  broken  thighs. 
From  the  large  mass  of  strong  muscles  surrounding  the  bone,  from 
there  being  only  one  point  of  solid  contact,  and  no  other  bone  to 
assist  in  keeping  it  steady,  the  thigh-bone  is  the  most  difficult  to 
be  placed,  and  most  easy  to  be  displaced,  of  any  in  the  human 
frame.  From  long  experience,  I  am  convinced  that  bending  the 
thigh  and  laying  it  on  the  outside,  will  not  insure  a  straight  and 
even  union;  and  I  appeal  to  those  who  have  seen  many  fractured 
thighs  treated  in  this  manner,  if  the  broken  ends  of  the  bone  do 
not  frequently  ride  over  each  other,  in  consequence  of  which  the 
broken  thigh  is  often  made  shorter  than  the  other,  and  the  foot  in 
walking  turns  outward.  These  defects,  if  they  are  not  very  wrong, 
become  palliated,  and  less  discernible,  from  the  person  being  ac- 
customed to  meet  them,  by  lowering,  as  he  walks,  the  pelvis  on 
the  defective  side.     But  the  fact  is  as  I  have  stated,  and  has  often 


AND  DISLOCATIONS.  ^6t 

raised  in  my  mind  great  objections  to  placing  fractured  thighs  on 
the  outside.  I  conceive  that  the  displacement  of  the  bones  in  this 
case  is  often  owing  to  the  weight  of  the  pelvis  bearing  down  the 
superior  part  of  the  broken  thigh  into  a  depression  in  the  bed;  for 
if  this  should  give  way,  and  become  hollow,  the  whole  of  the 
thigh,  as  far  as  the  fractured  part,  will  be  carried  down  and  sink 
into  it,  while  the  lower  end  of  the  bone  and  knee  retaining  the 
first  position  in  which  they  were  placed,  an  obtuse  angle  will  be 
formed;  as  it  is  impossible  to  keep  on  bandages  and  splints  so 
tight  as  to  counteract  a  deviation  from  the  right  position,  when  ef- 
fected by  such  powerful  means.  In  this  case,  very  able  surgeons, 
to  my  knowledge,  have  been  and  may  again  be  deceived;  for  if 
the  bandage  be  undone,  and  the  thigh  viewed  in  this  position,  the 
outline  of  the  upper  part  of  the  thigh  down  to  the  knee  will  be 
perfect,  and  it  will  appear  straight:  but  there  is  often  a  protrusion 
of  the  upper  end  of  the  fracture  internally,  which  is  not  visible, 
and  which  nothing  but  accurate  examination  with  the  fingers  can, 
through  that  vast  thickness  of  soft  parts,  discover.  If  it  be  not 
noticed  in  time,  (that  is,  very  early  after  the  accident,  perhaps 
within  a  week  or  ten  days,  according  to  the  uniting  disposition, 
which  varies  in  different  subjects  and  from  different  causes,)  the 
discovery  will  be  made  too  late;  an  adhesion  will  soon  take  place 
between  the  ends  of  the  bones  and  the  contiguous  muscles;  bony 
matter  will  soon  be  formed  in  the  interspace;  and  it  will  not  be  in 
our  power  to  remedy  this  effect:  of  course  the  leg  and  foot  will  in 
future  turn  outwards.  These  considerations  have  led  me,  con- 
trary to  my  education,  to  prefer  laying  broken  thighs  in  a  line 
with  the  body,  conceiving  that  in  this  situation  the  fracture  is  less 
liable  to  be  displaced,  and  that  any  deviation  from  the  straight 
line,  whether  above  or  below,  or  on  either  side,  is  more  readily 
discernible  and  more  easily  rectified.  I  do  not  wish  to  insinuate 
that  placing  fractured  thighs  in  the  straight  position  is  a  new  idea. 
I  know  it  has  been,  and  is  now,  practised  by  many — I  only  mean 
to  say,  that,  though  I  have  long  been  accustomed  to  see  them  laid 
in  a  bent  posture,  for  the  reasons  above  given  I  prefer  the  other: 
at  the  same  time,  in  case  of  laying  fractures  either  of  the  leg  or 
thigh  in  a  straight  position,  we  need  not  lose  sight  of  Mr,  Pott'a 
first  and  great  principle,  the  benefit  and  use  of  relaxing  the  mus- 
voL.  r.  K  k 


258  REMARKS    ON  FRACTURES 

cles;  and  hj  raising  the  thigh  toward  the  body,  supporting  that 
with  pillows,  and  bending  the  knee  to  a  certain  degree,  the  same 
end  may  be  obtained. 

There  is  one  case  where  we  can  have  no  choice — I  mean  when 
both  thighs  are  broken.  Under  these  circumstances  it  is  evident 
that  the  patient  must  lie  on  his  back,  and  consequently  the  thighs 
must  be  in  a  straight  position:  when  thus  of  necessity  place'd,  they 
do  well;  and  this  is  a  strong  argument  in  favour  of  the  practice. 

But  if  there  be  any  doubt  of  superiority  between  the  straight 
and  bent  position  of  fractured  thighs,  there  is  a  new  contrivance 
which  I  conceive  must  turn  the  scale  in  favour  of  the  former,  as  in 
that  posture,  the  introduction  of  any  kind  of  machine  under  the 
patient  to  relieve  him  from  natural  evacuations,  and  the  efforts  to 
raise  and  assist  himself,  which  from  an  innate  sense  of  cleanliness 
he  would  otherwise  almost  involuntarily  make,  are  by  that  invention 
wholly  avoided;  and!  am  sure  every  gentleman  of  the  faculty  will 
agree  with  me,  that  those  circumstances  are  very  often  the  cause 
of  disturbing  and  displacing  fractured  thigh-bones,  in  whatever 
situation  they  may  be  placed. 

The  contrivance  consists  in  a  double  bed:  the  upper  one  has  an 
opening  in  the  sacking,  in  a  suitable  place,  and  of  a  proper  size, 
to  which  a  thin  mattress,  blanket,  and  sheet,  are  made  to  corre- 
spond, with  a  similar  aperture:  this,  by  a  very  simple  piece  of 
mechanism,  may  be  elevated  to  a  sufficient  height  for  the  nurse  to 
introduce  a  proper  receptacle  between  that  and  the  fixed  bed.  The 
patient  being  relieved,  the  bed  is  gently  let  down  again  upon  the 
under  one,  a  thin  cushion  being  placed  on  the  under  bed,  to  fill  up 
the  opening  and  make  the  upper  bed  level. 

Such  a  machine  has  been  long  and  much  wanted  on  many  occa- 
sions. Indeed  it  is  surprising,  that  among  so  many  inventions  to 
promote  gratification  and  convenience,  so  little  has  been  done  for 
the  accommodation  of  the  bed-ridden,  or  persons  who  are  unable, 
from  various  causes,  to  leave  their  beds.  These  unfortunate  be- 
ings, in  this  age  of  ingenuity  and  science,  are  still  left  in  the  same 
state  that  they  have  been  obliged  to  submit  to  for  centuries  past. 

It  is  well  known  that  the  common  method  of  refreshing  beds 
under  sick  persons  is  by  removing  the  patient  to  one  sideof  tiie 
bed,  while  the  other  side  is  shaken  up;  after  which  he  is  again 


f 

AND    DISLOCATIONS.  259 

removed  till  the  opposite  side  is  made.  This  must  be  allowed  to 
be  only  a  sort  of  half-comfort;  the  bed  can  be  but  imperfectly 
made,  and  can  have  no  opportunity  of  becoming  cool;  consequent- 
ly the  patient  is  again  consigned  to  the  annoyance  of  his  own  heat 
and  perspiration;  and  infractures,  rheumatism,  gout, and  many  other 
cases  which  might  be  mentioned,  even  this  refreshment  it  is  some- 
times impossible  to  give.  By  this  contrivance,  the  upper  bed  may 
be  raised,  and  the  under  one  completely  made,  as  often  as  may  be 
thought  necessary  or  agreeable,  without  disturbing  or  discomposing 
the  patient. 

If  it  be  objected,  that  though  the  under  bed  may  be  made,  the 
upper  one  cannot  be  changed,  it  may  be  answered,  that  the  under 
one  is  of  the  most  consequence,  being  the  same  feather-bed  or 
mattresses  the  person  is  accustomed  to  lie  on,  while  the  upper  one 
has  only  a  thin  mattress,  blanket,  and  sheet;  but  by  means  of  a 
bar  which  was  added  for  this  and  other  purposes,  it  will  be  found 
that  the  upper  bed  may  also  at  any  time  be  occasionally  changed. 

After  many  years  experience  of  the  distressful  situation  of  per- 
sons who  from  various  complaints  could  not  be  removed  from  their 
loathsome  beds,  but  have  been  obliged  to  remain  in  them  till  the 
very  bed  and  sacking  have  rotted  under  them — after  having  so  of- 
ten witnessed  the  difficulty,  danger,  and  not  unfrequently  the  inju- 
ry, which  is  caused  by  forcing  a  bed-pan  under  a  patient  in  cases 
of  fractures,  painful  wounds,  rheumatic  or  gouty  affections,  and 
many  other  instances  which  might  be  mentioned — after  having 
seen  many  cases  in  which  it  was  absolutely  impossible  to  intro- 
duce it  at  all,  or  its  more  filthy  substitute  (a  draw-sheet),  when 
the  nurse  could  use  no  other  than  the  most  disgusting  and  imper- 
fect means  of  cleaning  the  patient — it  cannot  be  wondered  at  if 
I  feel  great  pleasure  in  communicating  a  contrivance,  which  will 
gently  raise  the  patient,  permit  the  bed  to  be  fresh  made,  and  give 
him  the  exquisite  delight  of  coolness  and  cleanliness. 

It  is  then  my  opinion,  that  not  only  in  fractures  and  dislocations 
of  the  lower  limbs,  both  simple  and  compound,  but  in  diseases  of 
the  knee,  hip,  hlid  spine;  in  fevers,  when  from  long  continued  and 
unvaried  position,  added  to  moisture  and  heat,  excoriations  and 
often  extensive  mortifications  take  place  on  the  nates,  hips,  and 
lower  part  of  the  back;  in  fistulas  in  perineo;  in  the  gout  and 


260  REMARKS    ON    FRACTURES,  &.C. 

rheumvitism,  in  which  the  least  motion  is  often  torture;  in  the  na- 
tural confluent  small-pox;  in  child-bearing,  particularly  in  those 
cases  where  puerperal  inflammation  or  clanger  of  flooding  requires 
a  strict  horizontal  posture;  in  cases  of  insanity,  when  coercion  is 
necessary;  in  sickness,  weakness  from  age,  or  any  other  infirmity, 
w':iich  prevents  persons  from  leaving  their  beds,  or  from  moving  or 
being  moved  in  them,  the  double  bed  will  be  found  of  admirable 
use  and  assistance. 

It  was  invented  by  Mr.  Henry  Earle  at  a  very  early  age,  and 
soon  after  the  commencement  of  his  professional  studies.  Inde- 
pendent of  any  partiality,  which  on  that  score  I  might  conceive 
for  the  invention,  it  appeared  to  me,  and  indeed  is  allowed  by 
every  one  who  has  seen  it,  so  well  calculated  to  be  useful  on  a 
great  variety  of  occasions,  that  I  have  been  induced  to  treat  on  it 
more  at  large  in  a  Letter;  from  which  this  is  an  extract,  and  in 
which  its  many  comforts  and  utilities  are  pointed  out. 

Representations  of  the  bed  will  also  there  be  found;  and  con- 
ceiving they  would  not  be  unacceptable  or  unuseful,  I  have  inserted 
them  in  this  work.         E. 

*  Containing  some  '  Observations  on  Fractures  of  the  Lower  Limbs.  To 
which  is  added,  an  Account  of  a  Contrivance  to  administer  Cleanliness  and 
Comfort  to  the  Bed-ridden,  or  Persons  confined  to  Eed  by  Age,  Accidents^ 
Sickness,  or  any  other  Infirmity.     With  Explanatory  Plates.        E. 


'262  REMARKS  ON  FRACTURES,  &C. 


PLATE  I. 


Represents  the  original  bed  at  St.  Bartholomew's  hospital,  3  ieet6  inches 
wide  by  6  feet  4  inches  in  length.  This  being  made  expressly  for  the  pur- 
pose, the  upper  bed  corresponds  exactly,  and  fits  in  with  the  other ;  but 
being  intended  for  public  and  constant  use,  it  is  heavier  and  stronger  tlian 
is  necessary  for  private  families. 


Fig.  1,  shows  the  upper  bed  lying  on  the  under  one. 
Fig.  2,  the  upper  bed  raised  to  a  convenient  height. 


364  REMARKS  ON  FRACTURES,  &C. 


PLATE  11. 

Shows  the  improved  plan,  in  which  the  upper  bed  is  made  of  sufficient 
width  for  one  person,  but  it  is  intended  to  be  placed  oh  and  fixed  to  any  bed 
of  any  breadth. 

The  upper  bed  is  seen  lying  on  the  lower  bed, — and  also  as  it  appears 
when  raised  up. 

Specimens  of  the  bed  ma}' be  seen  at  Mr.  Oakley'?,  No.  8,  Old  Bond  Street, 
who  has  undertaken  the  manufacture  of  them. 


J^LATJi  1 


JPl,^4.TE  Z 


A'/7V/7  /  Focyc  2f2  or  'Zfi-f  Vol.  1 


AND  DISLOCATIONS.  263 


COMPOUND  FRACTURES. 

I  USE  the  term  compound  fracture  in  the  sense  in  which  the 
English  have  always  used  it;  that  is,  to  imply  a  broken  bone 
complicated  with  a  wound. 

In  this  kind  of  case  the  first  object  of  consideration  is, 
whether  the  preservation  of  the  fiacrured  limb  can,  with 
safety  to  the  patient's  life,  be  attempted;  or,  in  other  words, 
whether  the  probable  chance  of  destruction,  from  the  nature 
and  circumstances  of  the  accident,  is  not  greater  than  it 
would  be  from  the  operation  of  amputation.  Many  things  may 
occur  to  make  this  the  case.  The  bone  or  bones  being  broken 
into  many  dilTerent  pieces,  and  that  for  a  considerable  extent,  as 
happens  from  broad  wheels,  or  other  heavy  bodies  of  large  surface, 
passing  over,  or  falling  on  such  limbs;  the  skin,  muscles,  tendons, 
&c".  being  so  torn,  lacerated,  and  destroyed,  as  to  render  gangrene 
and  mortification  the  most  probable  and  most  immediate  conse- 
quence; the  extremities  of  the  bones  forming  a  joint  being  crushed, 
or  as  it  were  comminuted;  and  the  ligaments  connecting  such 
bones  being  torn  and  spoiled;  are,  among  others,  sufficient  reasons 
for  proposing  and  for  performing  immediate  amputation — reasons, 
which  (notwithstanding  any  thing  that  may  have  been  said  to  the 
contrary)  long  and  reiterated  experience  has  approved,  and  which 
are  vindicable  upon  every  principle  of  humanity  or  chirurgic 
knowledge. 

When  a  surgeon  says,  that  a  limb,  which  has  just  suffered  a 
particular  kind  of  compound  fracture,  ought  rather  to  be  imme- 
diately cut  off,  than  that  any  attempt  should  be  made  for  its  pre- 
servation, he  does  not  mean,  by  so  saying,  that  it  is  absolutely  im- 
possible for  such  limb  to  be  preserved  at  all  events;  he  is  not  to 
be  supposed  to  mean  so  much  in  general,  though  sometimes  even 
that  will  be  obvious;  all  that  he  can  truly  and  justly  mean  is,  that 
from  the  experience  of  all  time  it  has  been  found,  that  the  attempts 
to  preserve  limbs  so  circumstanced,  have  most  frequently  been 
frustrated  by  the  death  of  the  patients,  in  consequence  of  such 
injury;  and  that  from  the  same  experience  it  has  been  found,  that 

VOL.  I.  L I 


266  REMARKS  ON  FRACTURES 

the  chance  of  death  from  amputation  is  by  no  means  equal  to  that 
arising  from  such  kind  of  fracture. 

Every  man  knows,  that  apparently  desperate  cases  are  some- 
times cured;  and  that  limbs  so  shattered  and  wounded,  as  to  render 
amputation  the  only  probable  means  for  the  preservation  of  life, 
are  now  and  then  saved.  This  is  an  uncontroverted  fact,  but  a 
fact  which  proves  very  little  against  the  common  opinion;  because 
every  man  of  experience  also  knows,  that  such  escapes  are  very 
rare,  much  too  rare  to  admit  of  being  made  precedents,  and  that  the 
majority  of  such  attempts  fail.y 

This  consideration  relative  to  amputation  is  of  the  more  import- 
ance, because  it  most  frequently  requires  immediate  determina- 
tion; every  minute  of  delay  is,  in  many  instances,  to  the  patient's 
disadvantage;  and  a  very  short  space  of  time  indeed  frequently 
makes  all  the  difference  between  probable  safety  and  fatality.  If 
these  cases  in  general  would  admit  of  deliberation  for  two  or  three 
days,  and  during  that  time  such  circumstances  might  be  expected 
to  arise,  as  ought  necessarily  to  determine  the  surgeon  in  his  con- 
duct without  adding  to  the  patient's  hazard,  the  difference  would 
be  considerable;  the  former  would  not  seem  to  be  so  precipitate 
in  his  determination,  as  he  is  frequently  thought  to  be;  and  the 

y  The  baron  Van  Swieten,  writing,  as  many  others  have  done,  that  is, 
theoretically,  on  surgery,  advises  us,  in  tlie  case  of  very  bad  compound  frac- 
tures, which  may  most  probahly  require  amputation,  to  defer  the  operation, 
until  we  have  tried  the  force  of  antiseptic  fomentation  and  applications  of 
like  kind  for  two  or  three  days ;  and  this  opinion  and  advice  he  builrls,  in 
some  meaaure,  on  a  remarkable  success  of  La  Motte,  in  a  seemingly  despe- 
rate case,  of  li  man's  leg  mashed  by  the  wheel  of  a  heavy  carriage. 

That  De  La  Motte's  patient  esc:)ped,  I  make  no  doubt,  because  he  has 
said  SO;  but  the  surgeon  showed  much  more  rashness  in  attempting  to  save 
such  a  limb,  than  he  would  liave  done  in  the  amputation  of  it :  the  operation 
would  have  been  the  more  justifiable  practice.  With  regard  to  the  baron's 
advice,  to  stay  two  or  three  days,  I  take  the  liberty  to  add,  that  if  you  do  that, 
stay  several  more  ;  for  at  the  end  of  that  time  (I  mean  two  or  three  days) 
the  patient  will  have  very  little  chance  indeed  from  the  operation,  much  less 
,  than  lie  would  have  had  at  the  time  of  tlie  accident. 

I  should  be  very  sorry  to  be  Uiouglit  a  patron  or  an  adviser  of  rashness  or 
cruelty  ;  but  in  what  I  have  he.iv.  said,  I  believe  1  shall  have  every  man  in  (he 
profession,  who  lias  either  true  ihumanity  or  sound  judgment,  founded  on  ex- 
perience, on  my  side. 


AND  DISLOCATIONS.  267 

latter,  being  more  convinced  of  the  necessity,  would  submit  to  it 
with  less  reluctance.  But  unhappily  for  both  parties,  this  is  seldom 
the  case;  and  the  first  opportunity  having  been  neglected  or  not 
embraced,  we  are  very  frequently  denied  another.  Here  there* 
fore  the  whole  exertion  of  a  mans  judgment  is  required,  that  he 
may  neither  rashly  and  unnecessarily  deprive  his  patient  of  a  limb, 
nor,  through  a  false  tenderness  and  timidity,  suffer  him  to  perish 
by  endeavouring  to  preserve  such  limb.  Some  degree  of  address 
is  also  necessary  upon  such  occasion,  in  order  to  convince  the 
patient,  that  what  seems  to  be  determined  upon  hastily  and  with 
precipitation,  will  not  safely  admit  of  longer  deliberation.* 

The  limb  being  thought  capable  of  preservation,  the  next  con- 
sideration is  the  reduction  of  the  fracture.    The  ease  or  difficulty 

«  That  there  are  many  cases  which,  from  the  extent  of  the  laceration  or 
from  iisemorrhage,  particular!}  in  the  leg,  where  the  interosseal  artery  is  torn 
by  the  ragged  ends  of  the  bones,  and  from  other  circumstances,  it  may  be 
necessary  to  proceed  to  immediate  amputation,  must  be  allowed.  But  ex- 
cept in  cases  of  extreme  necessltyj  I  must  say,  that  sometimes,  where  the  ap- 
pearances scarcely  furnish  the  glimmering  of  a  bope  of  ultimately  saving  the 
limb,  if  the  person  appeared  of  a  robust  over-full  habit,  I  should  be  inclined 
to  wait,  and  to  put  off'  the  operation  until  inflammation  had  taken  place,  and 
bad  subsided,  and  the  patient  had  changed  the  high  and  boisterous  state  of 
health  which  he  enjoyed  at  the  time  of  meeting  with  the  accident,  for  a 
quieter  or  more  temperate  circulation,  when  I  conceive  he  would  stand  a 
better  chance  of  recovering  from  the  operation.  I  will  here  quote  two  similar 
accidents  which  terminated  very  differently  : — 

A  stout  lusty  man,  of  a  full  habit  of  body,  was  employed  at  the  European 
Museum  to  hang  some  pictures.  When  on  the  ladder,  he  fell  down  with  a 
heavy  picture  in  liis  hands,  by  which  his  right  foot  and  ancle  were  crushed, 
and  dreadfully  mangled.  Though  there  was  very  little  probability  of  the 
limb  being  saved,  it  was  judged  right  to  attempt  it.  I  did  not  see  him  at 
first,  but  afterwards  in  consultation,  when  it  appeared  to  me  impossible  to 
preserve  the  limb ;  but  as  his  habit  was  apparently  gi'oss  and  full,  it  was 
agreed  to  wait  some  time  longer.  The  quantity  of  discharge,  low  diet,  and 
proper  medicines  lowered  his  constitution  to  a  pitch  much  inferior  to  high 
health.  He  was  now  evidently  losing  ground  ;  and  as  there  remained  not  the 
most  distant  prospect  of  preserving  the  limb,  it  was  amputated.  Without 
any  adverse  circumstances,  he  got  well,  and  remains  a  healthy  man. 

A  gentleman,  getting  up  on  a  library-ladder,  fell  down,  and  received  a 
very  bad  compound  fracture  of  the  leg  :  it  was  judged,  in  consuliation,  im- 
possible to  save  the  limb,  and  immediate  amputation  took  place.  Inflammatoiy 
symptoms  succeeded  so  high  as  to  cause  his  death.        E, 


268  EEMARKS  ON  FRACTURES 

attending  this  depends  not  only  on  the  general  nature  of  the  case, 
but  on  the  particular  disposition  of  the  bone  with  regard  to  the 
wound. 

If  the  bone  be  not  protruded  forth,  the  trouble  of  reducing,  and 
of  placing  the  fracture  in  a  good  position,  will  be  much  less  than 
if  the  case  be  otherwise;  and  in  the  case  of  protrusion  or  thrusting 
forth  of  the  bone  or  bones,  the  difficulty  is  always  in  proportion  to 
the  comparative  size  of  the  wound,  through  which  such  bone  has 
passed.  In  a  compound  fracture  of  the  leg  or  thigh,  it  is  always 
the  upper  part  of  the  broken  bone  which  is  thrust  forth.  If  the 
fraciure  be  of  the  transverse  kind,  and  the  wound  large,  a  mode- 
rate degree  of  extension  will  in  general  easily  reduce  it;  but  if  the 
fracture  be  oblique,  and  terminates,  as  it  often  does,  in  a  long 
sharp  point,  this  point  very  often  makes  its  way  through  a  wound 
no  larger  than  just  to  permit  such  extension.  In  this  the  very 
placing  the  leg  in  a  straight  position,  in  order  to  make  extension, 
obliges  the  wound  or  orifice  to  gird  the  bone  tight,  and  makes  all 
that  part  of  it,  which  is  out  of  such  wound,  press  hard  on  the  skin 
of  the  leg  underneath  it.  -In  these  circumstances,  all  attempts  for 
reduction  in  this  manner  will  be  found  to  be  impracticable;  the 
more  the  leg  is  stretched  out,  the  tighter  the  bone  will  be  begirt 
by  the  wound,  and  the  more  it  will  press  on  the  skin  underneath. 

Upon  this  occasion,  it  is  not  very  unusual  to  have  recourse  to 
the  saw,  and  by  that  means  to  remove  a  portion  of  the  protruded 
bone. 

I  will  not  say  that  this  is  always  or  absolutely  unnecessary  or 
wrong,  but  it  most  certainly  is  frequently  so.  In  some  few  in- 
stances, and  in  the  case  of  extreme  sharp-pointedness  of  the  ex- 
tremity of  the  bone,  it  may  be,  and  undoubtedly  is  right:  but  in 
many  instances,  it  is  totally  unnecessary. 

The  two  most  proper  means  of  overcoming  this  difficulty  are, 
change  of  posture  of  the  limb,  and  enlargement  of  the  wound.  In 
many  cases  the  former  of  these,  under  proper  conduct,  will  be 
found  fully  sufficient;  and  where  it  fails,  the  latter  should  always 
be  made  use  of.  Whoever  will  attend  to  the  effect,  which  putting 
the  leg  or  thigh  (having  a  compound  fracture  and  protruded  bone) 
into  a  straight  position  always  produces;  that  is,  to  the  manner 
in  which  the  wound  in  such  position  girds  the  bone,  and  to  the 


AND  DISLOCATIONS.  269 

increased  difficulty  of  reduction  thereby  induced,  and  will  then, 
by  changing  the  posture  of  such  limb  from  an  extended  one,  to 
one  moderately  bent,  observe  the  alteration  thereby  made,  in  both 
the  just  mentioned  circumstances,  will  be  satisfied  of  the  truth  of 
what  I  have  said,  and  of  the  much  greater  degree  of  ease  and 
practicability  of  reduction  in  the  bent,  than  in  the  extended  posi- 
tion; that  is,  in  the  relaxed,  than  in  the  stretched  state  of  the  mus- 
cles.    Reduction  being  found  impracticable,  either  by  extension 
or  change  of  posture,  the  obvious  and  necessary  remedy  for  this 
difficulty  is  enlargement  of  the  wound.     This  to  some  practi- 
tioners, who  have  not  seen  much  of  this  business,  appears  a  dis- 
agreeable circumstance,  and  therefore  they  endeavour  to  avoid 
it;   but  their  apprehensions  are  in  general  groundless  and  ill- 
founded.     In  enlarging  the  wound  there  is  neither  difficulty  nor 
danger;  it  is  the  skin  only  which  can  require  division;  and  in 
making  such  wound  there  can  be  no  possible  hazard.    It  is  need- 
less to  say  that  the  division  should  be  such  as  to  render  reduction 
easy;  or  to  remind  the  practitioner,  that  such  enlarged  opening 
may  serve  very  good  future  purposes,  by  making  way  for  the  ex- 
traction of  fragments,  and  the  discharge  of  matter,  sloughs,  &,c. 

If  the  bone  be  broken  into  several  pieces,  and  any  of  them  be 
either  totally  separated,  so  as  to  lie  loose  in  the  wound,  or  if  they 
be  so  loosened  and  detached  as  to  render  their  union  highly  im- 
probable, all  such  pieces  ought  to  be  taken  away;  but  they  should 
be  removed  with  all  possible  gentleness,  without  pain,  violencCj 
or  laceration,  without  the  risk  of  haemorrhage,  and  with  as  little 
poking  into  the  wound  as  possible.  If  the  extremities  of  the  bone 
be  broken  into  sharp  points,  which  points  wound  and  irritate  the 
surrounding  parts,  they  must  be  removed  also.  But  the  whole  of 
this  part  of  the  treatment  of  a  compound  fracture  should  be  exe- 
cuted with  great  caution;  and  the  practitioner  should  remember, 
that  if  the  parts  surrounding  the  fracture  be  violated,  that  is,  be 
torn,  irritaied,  and  so  disturbed  as  to  excite  great  pain,  high  in- 
flammation, &c.  it  is  exactly  the  same  thing  to  the  patient,  and  to 
the  event  of  the  case,  whether  such  violence  be  the  necessary  con- 
sequence of  the  fracture,  or  if  his  unnecessary  and  awkward  mau- 
liier  of  poking  into,  and  disturbing  the  wound.  The  great  objects 
of  fear  and  apprehension  in  a  compound  fracture  (that  is,  in  the 


270  REMARKS  ON  FRACTURES 

first  or  early  state  of  it)  are,  pain,  irritation,  and  inflammation; 
these  are  to  be  avoided,  prevented,  and  appeased  by  all  possible 
means,  let  every  thing  else  be  as  it  may;  and  although  certain 
things  are  always  recited,  as  necessary  to  be  done,  such  as  remo- 
val of  fragmen's  of  bone,  of  foreign  bodies,  &c,  &c.  &c.  yet  it  is 
always  to  be  understood,  that  such  acts  may  be  performed  with- 
out prejudicial  or  great  violence,  and  without  adding  at  all  to  the 
risk  or  hazard  necessarily  incurred  by  the  disease. 
■  Reduction  of  or  setting  a  compound  fracture  is  the  same  as  in 
the  simple;  that  is,  the  intention  in  both  is  the  same,  viz.  by  means 
of  a  proper  degree  of  extensiQn  to  obtain  as  apt  a  position  of  the 
ends  of  the  fracture  with  regard  to  each  other,  as  the  nature  of  the 
care  will  admit,  and  thereby  to  produce  as  perfect  and  as  speedy 
onion  as  possible. 

To  repeat  in  this  place  what  has  already  been  said  under  the 
head  of  extension,  would  be  tedious  and  unnecessary.  If  the  argu- 
ments there  used  for  making  extension,  with  the  limb  so  moderately 
bent  as  to  relax  the  muscles,  and  take  off  their  power  of  resistance, 
have  any  force  at  all,  they  must  have  much  more  when  applied 
to  the  present  case:  if  it  be  allowed  to  be  found  very  painful  to 
extend,  or  to  put,  or  keep  on  the  stretch,  muscles  which  are  not 
at  all  or  but  slightly  wounded,  and  only  liable  in  such  extension 
to  be  pricked  and  irritated,  it  is  self-evident  that  it  must  be  much 
more  so  when  the  same  parts  are  torn  and  wounded  considerably; 
when  the  ends  of  the  fractured  bone  have  made  their  way  quite 
through  them,  divided  the  skin,  and  laid  all  open  to  the  access  of 
the  air. 

Every  consequence  which  does  or  may  be  supposed  to  flow  from 
wound,  pain  or  irritation,  in  consequence  of  violence,  must  neces- 
sarily be  much  greater,  when  a  lacerated  wound,  and  that  made 
by  the  bone,  is  added  to  the  fracture;  not  to  mention  the  ills  arising 
from  extending  or  stretching  out  muscles  already  torn  or  half 
divided. 

One  moment's  reflexion  must  be  sufficient  to  convince  any  rea- 
sonable man:  but  experience  is  the  only  proper  test  of  all  these 
kinds  of  things.  Let  this  method  of  treatment  then  be  fairly  and 
properly  subjected  to  it;  and  if  the  great  advantage  of  the  one  over 
the  other  does  not  appear,  that  is,  if  the  less  sensation  of  pain  by 


AND  DISLOCATIONS,  271 

the  patient,  and  the  more  huppy,  more  perfect,  and  more  expedU 
tious  accomplishment  of  his  purpose  by  the  surgeon,  do  not  deter- 
mine greatly  in  favour  of  relaxed  position,  I  am,  and  have,  for  a 
considerable  length  of  time,  been  greatly  misiaken. 

The  wound  dilated,  (if  necessary,)  loose  pieces  removed,  (if 
there  were  any,)  and  the  fracture  reduced,  and  placed  in  the  best 
possible  position,  the  next  thing  to  be  done  is  to  apply  a  dressing. 

On  this  subject  a  great  deal  has  been  said  by  writers,  particu- 
larly by  such  of  them  as  have  implicit  faith  in  external  applica- 
tions; but,  in  order  to  be  able  to  execute  this  part  of  the  process 
properly,  a  man  has  only  to  ask  himself.  What  are  the  intentions 
which,  by  any  kind  of  dressing  to  a  compound  fracture,  he  means 
to  aim  at  the  accomplishment  of?  And  a  rational  answer  to  this 
will  give  hiai  all  thai  he  can  want  to  know. 

The  dressing  necessary  in  a  compound  fracture  is  of  two  kinds; 
viz.  that  for  the  wound,  and  that  for  the  limb.  By  the  former, 
we  mean  to  maintain  a  proper  opening  for  the  easy  and  free  dis- 
charge of  gleet,  sloughs,  matter,  extraneous  bodies,  or  fragments 
of  bone,  and  this  in  such  manner,  and  by  such  means,  as  shall 
give  ihe  least  possible  pain  or  fatigue,  shall  neither  irritate  by  its 
qualities,  nor  oppress  by  its  quantity,  nor  by  any  means  contribute 
to  the  detention  or  lodgement  of  what  ought  to  be  discharged.  By 
the  latter,  our  aim  should  be  the  prevention  or  removal  of  inflam- 
mation, in  order,  if  the  habit  be  good,  and  all  other  circumstances 
fortunate,  that  the  wound  may  be  healed,  by  what  the  surgeons  call 
the  first  intention,  that  is,  without  suppuration  or  abscess;  or  that 
not  being  practicable,  that  gangrene  and  mortification,  or  even 
very  large  suppuration  may  be  prevented,  and  such  a  moderate 
and  kindly  degree  of  it  established  as  may  best  serve  the  purpose 
of  a  cure.  The  first  therefore,  or  the  dressing  for  the  wound,  can 
consist  of  nothing  better,  or  indeed  so  good,  as  soft  dry  lint,  laid 
on  so  lightly  as  just  to  absorb  the  sanies,  but  neither  to  distend 
the  wound,  nor  be  the  smallest  impediment  or  obstruction  to  the 
discharge  of  matter.  This  lint  should  be  kept  clear  of  the 
edges,  and  the  whole  of  it  should  be  covered  with  a  pledget  spread 
with  a.soft  easy  digestive.  The  times  of  dressing  must  be  deter- 
mined by  the  nature  of  the  case:  if  the  discharge  be  small  or  mo- 
derate, once  in  twenty-four  hours  will  be  sufficient;  but  if  it  be 


272  REMARKS    ON    FRACTURES 

large,  more  frequent  dressing  will  be  necessary,  as  Aveli  to  pre- 
vent offence,  as  to  remedy  the  inconveniences  arising  from  a  great 
discharge  of  an  irritating  sharp  sanies. 

The  method  of  treating  the  limb,  with  a  view  to  the  preven- 
tion of  such  accidents  and  symptoms,  as  pain,  inflammation,  and 
laceration  of  parts,  are  likely  to  produce,  is  different  with  different 
practitioners;  some  using,  from  the  very  first,  relaxing,  greasy 
applications;  others  applying  medicines  of  very  different  nature. 
Both  these  may  be  right  conditionally,  that  is,  according  to  dif- 
ferent circumstances  in  the  cases,  but  they  cannot  be  equally 
so  in  the  same  circumstances. 

Many  practitioners  are  accustomed  to  envelope  compound  frac- 
tures in  a  soft,  warm,  relaxing  cataplasm  from  the  very  first; 
whether  the  limb  be  in  a  tense  swollen  state,  or  not.  This,  if  I 
may  take  the  liberty  of  saying  so,  appears  to  me  to  be  injudicious. 
When  from  neglect,  from  length  of  time  passed  without  assist- 
ance, from  misconduct  or  drunkenness  in  the  patient,  from  awk- 
wardness and  unhandiness  in  the  assistants,  or  from  any  other 
cause,  a  tension  has  taken  possession  of  the  limb,  and  it  is  be- 
come tumid,  swollen,  and  painful,  a  warm  cataplasm  is  certainly 
the  best  and  most  proper  application  that  can  be  made,  and  that 
for  very  obvious  reasons:  the  state  of  the  parts  under  these  cir- 
cumstances is  such,  that  immediate  union  is  impossible,  and  no- 
thing but  a  free  and  plentiful  suppuration  can  dissipate  or  remove 
impending  mischief:  every  thing  therefore  which  can  tend  toward 
relaxing  the  tense,  swollen,  and  irritable  state  of  the  parts  con- 
cerned, must  necessarily  be  right;  the  one  thing  aimed  at  (plenti- 
ful suppuration)  cannot  be  accomplished  without  it.  But  when 
the  parts  are  not  in  this  state,  the  intention  seems  to  be  very  dif- 
ferent. To  relax  swollen  parts,  and  to  appease  pain  and  irrita- 
tion by  such  relaxation,  is  one  thing;  to  prevent  inflammatory  de- 
fluxion  and  tumefaction  is  certainly  another;  and  they  ought  to  be 
aimed  at  by  very  different  means.  In  the  former  a  large  suppura- 
tion is  a  necessary  circumstance  of  relief,  and  the  great  means  of 
cure;  in  the  latter  it  is  not,  and  a  very  moderate  degree  of  it  is  all 
that  is  required.  The  warm  cataplasm,  therefore,  although  it  be 
the  best  application  that  can  be  made  use  of  in  the  one  case,  is 


AND  DISLOCATIONS.  273 

certainly  not  so  proper  in  the  other,  as  applications  of  a  more  dis- 
cutient  kind,  such  as  mixtures  of  spirit,  vini.,  vinegar  and  water, 
with  crude  sal  ammoniac,  spirit,  mindereri,  acet.  litharg.,  and 
medicines  of  this  class,  in  whatever  form  the  surgeon  may  choose. 
By  these,  in  good  habits,  in  fortunately  circumstanced  cases,  and 
with  the  assistance  of  what  should  never  be  neglected,  I  mean 
phlebotomy,  and  the  general  antiphlogistic  regimen,  inflammation 
may  sometimes  be  kept  off,  and  a  cure  accomplished,  without 
large  collections  or  discharges  of  matter,  or  that  considerable  de- 
gree of  suppuration,  which,  though  necessary  in  some  cases,  and 
almost  unavoidable  in  others,  are  and  must  be  rather  promoted 
and  encouraged  than  retarded  or  prevented,  by  warm  relaxing  ap- 
plications of  the  poultice  kind.* 

*  The  principal  cause  of  the  inflammation,  and  the  consequent  bad  symp- 
toms which  so  frequently  take  place  in  compound  fructures,  appears  to  arise 
from  the  admission  of  air  into  the  wound  among  the  fractured  bones;  for  we  see 
that  bones  may  be  broken,  ligaments  and  tendons  may  be  bruised,  torn,  and 
wounded  in  any  manner,  and  will  unite,  heal,  and  do  well  again,  like  other 
soft  parts,  provided  no  air  gains  admission  :  but  if  that  is  suffered  to  enter,  it 
too  often  lights  a  fire  which  the  art  of  surgery  cannot  quench.  The  stimu- 
lating influence  of  air  on  diseased  cavities,  is  evident  on  many  occasions.  In 
the  psoas  abscess,  matter  may  be  formed  and  increased,  so  as  to  make  a  swell- 
ing of  great  magnitude  ;  the  patient  will  notwithstanding  continwe  free  from 
fever :  but  from  the  moment  it  is  opened,  and  air  admitted,  a  hectic  fever 
takes  place.  Large  extravasations  of  blcod  will  remain  in  a  quiet  state  for 
any  length  of  time  till  they  are  re-absorbed,  provided  the  skin  remains  whole ; 
but  if  an  opening  is  made,  and  air  permitted  to  enter,  a  stimulus  is  applied, 
inflammation  is  excited,  ai>d  a  putrid  slough  of  the  sides  of  the  cavity  and  its 
contents  will  generally  be  the  consequence.  Many  other  instances  might  be 
adduced,  to  prove  that  air,  from  whatever  principle  it  acts,  is  certainly  the 
great  enemy  in  all  these  cases.  Our  first  aim  should  therefore  be  to  prevent 
it  from  entering,  or,  if  it  has  entered,  to  exclude  it;  and  this  may  frequently 
be  accomplished  by  closing  the  wound  as  soon  as  possible,  after  the  bones  are 
placed  in  their  proper  situation,  and  by  keeping  it  close  with  slips  of  sticking 
plaster;  or  in  some  cases  sutures  may  be  employed  with  advantage  :  it  should 
then  be  covered  with  proper  dressings,  such  as  dry  lint  and  sedative  applica- 
tions, avoiding  every  thing  greasy.  These  first  dressings  should  not  be  re- 
moved for  many  days,  unless  a  collection  of  matter  makes  it  necessary  to 
change  them.  By  these  means  the  wounds  in  the  soft  parts  may  often  be 
biought  to  heal  by  the  first  intention  ;  and  thus  compound  fractures,  unat- 
tended with  the  usual  long  train  of  evils  which  Mr.  Pott  has  so  well  described, 
will  frequently  unite,  and  give  no  more  trouble  than  simple  fractures.  The 
fortunate  termination  of  the  compound  fracture  in  his  own  leg,  was  proba- 
VOL.  I.  M  m 


Uli  REMARKS  ON  FRACTURES 

Compound  fractures  in  general  require  to  be  dressed  every  day; 
and  the  wounded  parts  not  admitting  the  smallest  degree  of  motioa 
without  great  pain,  perfect  quietude  becomes  as  necessary  as  fre- 
quent dressing. 

bly  owing'  to  the  air  being  excluded:  but  t!iis  arose  from  tlie  naUire  of  tl\e 
fracture,  rather  than  from  the  manner  in  whicli  it  was  treated,  as  the  idea  of 
preventing  the  first  admission  of  air,  in  these  c;ises,  was  not  at  th.it  time  at- 
tended to;  though,  while  they  were  clianging  tiieir  dressings,  by  means  of 
lamps  and  other  contrivances,  our  forefathers  endeavoured  to  correct  its  per- 
nicious effects,  which  they  ascribed  to  cold.  In  Mr.  Pott's  case,  the  fact  was, 
that  the  bone  had  made  its  way  through  the  skin  at  a  distance  from  tlie  frac- 
ture; so  that,  when  it  was  returned  into  its  place,  the  soft  parts  closed,  and 
prevented  the  air  from  getting  in ;  by  which  means  the  wound  healed  by 
the  first  intention.  I  have  now  under  my  care  a  man  who  had  a  compound 
fracture  of  the  leg.  The  wound  was  small,  easily  closed,  and  kept  so  by 
sticking  plaster:  as  no  bad  symptoms  followed,  the  first  dressings  were  suf- 
fered to  remain  a  fortnight,  at  the  end  of  which  time  the  wound  was  found 
healed,  and  the  bones  firm.  Had  it  not  been  thus  treated — on  the  contrary, 
had  the  dressings  been  removed,  and  the  air  suffered  to  enter — it  is  more 
than  probable  that  the  usual  bad  symptoms  would  have  arisen;  for  the  dan- 
ger in  compound  fractures  does  not  depend  on  the  size  of  the  wound.  If  air 
gets  in,  a  small  wound  is  equally  bad  as  a  large  one,  perhaps  worse,  by  con- 
fining the  matter  after  it  is  collected.  I  have  mentioned  this  case  as  it  occurs 
on  the  instant ;  but  could  adduce  many  more,  in  which  equal  success  has  at- 
tended this  mode  of  practice. 

The  benefit  arising  from  keeping  out  air,  in  these  cases,  was  an  observa- 
tion I  made  when  very  young  in  the  profession ;  and  practice  and  experience 
have  convinced  me  of  the  truth  of  it.  I  was  sent  tor,  many  years  ago,  to  a 
person  who  by  a  fall  had  a  compound  dislocation  of  the  joint  of  the  ancle. 
The  skin  was  torn  evenly,  as  if  it  had  been  divided  with  a  knife  :  I  could 
pass  my  finger  into  the  cavity  of  the  joint.  Being  aware  of  the  horrid  mis- 
chief which  is  usually  produced  by  air  being  admitted  into  tliesc  cavities,  I 
was  induced  to  try  what  would  be  the  consequences  of  its  entire  exclusion: 
accordingly  I  sewed  up  the  wound  close,  with  a  number  of  fine  stitches,  mere- 
ly passing  them  through  the  edges  of  the  skin,  and  then  applied  proper  dress- 
ing and  bandage.  The  wound,  to  my  great  surprise,  healed  by  the  first  inten- 
tion, without  more  inflammation  than  usually  attends  wounds  of  any  other  part. 
It  may  be  proper  to  remark,  that  at  the  same  time  the  man  had  received  so 
violent  a  contusion  on  his  back  as  to  render  his  lower  limbs  paralytic.  How  far 
the  want  of  nervous  influence  might  have  been  the  cause  of  the  small  degree 
of  inflammation  which  took  place,  I  cannot  determine.  It  is  a  case  which 
will  not  be  easily  paralleled,  and  no  one  can  suppose  that  I  mean  to  say  that 
this  plan  will  always  succeed  in  compound  fractures.  However,  the  attempt 
is  worth  making  in  most  cases,  as  no  detriment  can  arise  from  it ;  and  if  we 
gain  our  point,  it  is  a  most  important  one  to  the  patient,  who  avoids  a  tedious 


AND  DISLOCATIONS.  2T5 

The  common  bandage  therefore  (the  roller)  has  always  in  this 
case  been  laiu  aside,  ami  what  is  called  the  eighteen-tailcd  ban- 
dage substituted,  very  judicicuslj,  in  its  place.  Of  (his  I  have 
already  spoken  so  largely,  as  to  make  repetition  unnecessar3\ 

Splints,  that  is,  such  short  ones  as  are  most  commonly  made  use 
©f  in  simple  fractures,  are  by  all  forbid  in  the  compound,  and  that 
for  the  same  reason  which  ought  to  have  prevented  tnem  from 
having  ever  been  used  in  the  former;  viz.  because  t.;e  probable 
good  to  be  derived  from  them  can  be  but  little;  and  the  probable 
mischief  is  obvious  and  considerable. 

But  although  short  splints  are  for  many  reasons  palpably  im- 
proper, in  both  cases,  yet  those  of  proper  length,  those  which 
reach  from  joint  to  joint,  comprehend  them  both,  and  are  applied 
on  each  side  of  the  leg  only,  are  very  useful  both  in  the  simple 
and  in  the  compound  fracture;  as  they  may,  thus  applied,  be  made 
to  keep  the  limb  more  constantly  steady  and  quiet,  than  it  can  be 
kept  without  them. 

With  regard  to  position  of  the  limb,  I  have  already  been  so 
explicit,  when  speaking  of  the  simple  fracture,  that  to  say  any 
thing  more  about  it  here  would  be  an-  abuse  of  the  reader's 
time  and  patience.  The  only,  or  the  material  difference  between 
a  simple  and  a  compound  fracture,  as  far  as  relates  to  this  part 
of  the  treatment,  is,  that  as  the  parts  surrounding  the  broken  bone 
in  the  latter  are  more  injured,  and  consequently  more  liable  to 
irritation,  pain,  inflammation,  and  all  their  consequences,  there- 
fore every  method  and  means,  by  which  the  alleviation  of  such 
symptoms,  and  the  prevention  of  such  consequences  can  be  ob- 
tained, is  still  more  necessary  and  requisite.  Among  these  the 
posture  of  the'  limb  is  so  principal  a  circumstance,  that  without 
its  concurrence  every  other  will  be  fruitless.  The  points  to  be 
aimed  at  are,  the  even  position  of  the  broken  parts  of  the  bone, 
and  such  disposition  of  the  muscles  surrounding  thepi,  as  is  most 
suitable  to  their  wounded,  laceratied  state,  as  shall  be  least  likely 

confinement  of  perhaps  man)'-  months,  not  to  mention  all  the  concomitant 
evils.  During  this  healing  process  we  should  endeavour  to  prevent  inflam- 
mation from  taking  place  by  sedative  applications,  of  which  the  saturnine  are 
most  efficacious  ;  and  by  every  meanSj  both  internal  ^vd  external,  which  ex- 
perience suggests,        K 


376  REMARKS  ON  FRACTURES 

to  irritate  them,  by  keeping  them  on  the  stretch,  or  to  produce 
high  inflammation,  and  at  best  large  suppuration.  These,  I  say, 
are  the  ends  to  be  pursued;  and  how  much  the  position  of  the  limb 
does,  and  must  necessarily  contribute  to  the  advantage  or  disad- 
vantage just  recited,  must  be  so  obvious  to  any  body  capable  of 
reflexion,  that  nothing  more  need  be  said  about  it. 

At  the  beginning  of  these  sheets,  I  have  said,  that  it  was  not 
my  intention  to  write  a  regular  treatise,  but  only  to  throw  out  a 
few  hints  which  I  hoped  might  prove  useful  to  such  as  have  not 
yet  received  better  information.  The  part  of  my  subject  at  which 
I  am  now  arrived,  does  not  indeed  admit  of  much  more:  a  few 
general  precepts  are  all  which  a  writer  can  give:  the  particular 
method  of  conducting  each  particular  case  must  be  determined  by 
the  nature  of  that  case,  and  by  the  judgment  of  the  surgeon. 

Every  body  knows,  or  ought  to  know,  that  these  cases  of  all 
others  require  at  first  the  most  rigid  observance  of  the  antiphlo- 
gistic regimen;  that  pain  is  to  be  appeased,  and  rest  obtained,  by 
anodynes;  that  inflammation  is  to  be  prevented  or  removed  by  free 
and  frequent  bleeding,  by  keeping  the  body  open,  and  by  the  ad- 
ministration of  such  medicines  as  are  best  known  to  serve  such 
purposes;  and  that,  during  this  first  state  or  stage,  the  treatment 
of  the  limb  must  be  calculated,  either  for  the  prevention  of  inflam- 
matory tumefaction,  by  such  applications  as  are  in  general  known 
by  the  title  of  discutients;  or,  such  tumor  and  tension  having 
already  taken  possession  of  the  limb,  that  warm  fomentation  and 
relaxing  and  emollient  medicines  are  required. 

If  these,  according  to  the  particular  exigence  of  the  case,  prove 
successful,  the  consequence  is,  either  a  quiet  easy  wound,  which 
suppurates  very  moderately,  and  gives  little  or  no  trouble;  or  a 
wound,  attended  at  first  with  considerable  inflammation,  and  that 
producing  large  suppuration,  with  great  discharge  and  troublesome 
formation  and  lodgement  of  matter.  If,  on  the  other  hand,  our 
attempts  do  not  succeed,  the  consequence  is  gangrene  and  mor- 
tification. 

These  are  three  general  events  or  terminations  of  a  compound 
fracture,  and  according  to  these  must  the  surgeon's  conduct  be 
.  regulated. 


AND  DISLOCATIONS.  277 

In  Ihe  first  instance,  he  has  indeed  nothing  to  do  but  to  avoid 
doing  mischief,  either  by  his  manner  of"  dressing,  or  by  disturbing 
the  limb.  Nature  let  alone  will  accomplish  her  own  purpose; 
and  art  has  little  more  to  do  than  to  preserve  the  due  position  of 
the  limb,  and  to  take  care  that  the  dressing  applied  to  the  wound 
proves  no  impediment. 

In  the  second  stage,  that  of  formation  and  lodgement  of  matter, 
in  consequence  of  large  suppuration,  all  a  surgeon's  judgment  will 
sometimes  be  required  in  the  treatment  both  of  the  patient  and  his 
injured  limb.  Enlargement  of  the  present  wound,  for  the  more 
convenient  discharge  of  matter;**  new  or  counter  openings  for  the 
same  purpose,  or  for  the  extraction  of  fragments  of  broken  or  ex- 
foliated bone,  will  very  frequently  be  found  necessary,  and  must 
be  executed.  In  the  doing  this,  care  must  be  taken  that  what  is 
requisite  be  done,  and  no  more;  and  that  such  requisite  operations 
be  performed  with  as  little  disturbance  and  pain  as  possible:  the 
manner  of  doing  business  of  this  kind,  will  make  a  very  material 
difference  in  the  sufferings  of  the  patient. 

Very  contrary,  or  at  least  very  different  intentions,  seem  to  me 
to  require  the  surgeon's  very  particular  attention  in  the  two  parts 
of  this  stage  of  the  disease. 

Previous  to  large  suppuration,  or  considerable  collections  and 
lodgements  of  matter,  tumefaction,  induration,  and  high  inflamma- 
tion, attended  with  pain,  irritation,  and  fever,  require  evacuation 
by  phlebotomy,  an  open  belly,  and  antiphlogistic  remedies,  as 
well  as  the  free  use  of  anodynes,  and  such  applications  to  the  limb 
as  may  most  serve  the  purpose  of  relaxation.  But  the  matter 
having  been  formed  and  let  out,  and  the  pain,  fever,  &c.,  which 
were  symptomatic  thereof,  having  disappeared  or  ceased,  the  use 
and  purpose  of  such  medicines  and  such  applications  cease  also, 

*>  It  is  a  practice  with  some,  from  a  timidity  in  using  a  knife,  to  make  use 
of  bolsters  and  plaster-compresses  for  the  discharge  of  loi'ging  matter. 
Wliere  another  or  a  counter  opening  can  conveniently  and  safely  be  made, 
it  is  always  preferable,  the  compress  sometimes  acting  diametrically  opposite 
to  the  intention  with  which  it  is  applierl,  and  contributing  to  the  lodgement 
by  confining  the  matter  ;  beside  which,  it  requires  a  greater  degree  of  pres- 
sure to  make  it  efficacious,  than  a  limb  in  such  circumstances  generally  can 
bear. 


278  REMARKS  ON  FRACTURES 

and  they  ought  therefore  to  be  disconlinued.  By  evacuation,  &c., 
the  patient's  strength  has  necessarily  (and  indeed  properly)  been 
reduced:  by  cataplasm,  &c.,  the  parts  have  been  so  relaxed  as  to 
procure  an  abatement  or  cessation  of  inflammation,  a  subsidence 
of  tumefaction,  and  the  establishment  of  a  free  suppuration;  but, 
these  ends  once  fairly  and  fully  answered,  another  intention  arises, 
which  regards  the  safety  and  well-doing  of  the  patient,  nearly,  if 
not  full  as  much  as  the  former;  which  intention  will  be  neces- 
sarily frustrated  by  pursuing  the  method  hitherto  followed.  The 
patient  now  will  require  refection  and  support,  as  much  as  he  be- 
fore stood  in  need  of  reduction;  and  the  limb,  whose  indurated  and 
inflamed  state  hitherto  required  the  emollient  and  relaxing  poultice, 
will  now  be  hurt  by  such  kind  of  application,  and  stand  in  need 
of  such  as  are  endued  with  contrary  qualities,  or  at  least  such 
as  shall  not  continue  to  relax.  Good,  light,  easily  digested  nutri- 
ment, and  the  Peruvian  bark,  will  best  answer  the  purpose  of  in- 
ternals: the  discontinuation  of  the  cataplasms,  and  the  application 
of  medicines  of  the  corroborating  kind,  are  as  necessary  with  re- 
gard to  externals." 

In  short,  if  there  be  any  rationale  in  the  use.  of  the  cataplasm  in 
the  first  stage,  its  impropriety  in  the  second  must  be  evident  from 
the  same  principles.  So  also  with  regard  to  evacuation,  and  the 
antiphlogistic  regimen,  when  all  the  good  proposed  to  be  obtained 
by  them  has  been  received,  a  pursuit  of  the  same  method  must 
become  injurious,  and  that  for  the  same  reason  which  before 
rendered  it  necessary  and  beneficial. 

A  non-attention  to  this  has,  I  believe,  been  not  infrequently  the 
cause  of  the  loss  both  of  limbs  and  lives. 

Every  body  who  is  acquainted  with  surgery  knows,  that  in  the 
case  of  bad  compound  fracture,  attended  with  large  suppuration, 
it  sometimes  happens,  even  under  the  best  and  most  judicious 

'^  It  is  suvprising  how  lar.g'e  and  how  disagrreable  a  discharge  will  be  m:ide 
for  a  considerable  length  of  time,  in  some  instances,  from  the  detention  and 
irritation  of  a  splinter  of  bone.  If  therefore  such  discharge  be  made,  and  there 
be  neither  sinus  nor  lodgement  to  account  for  it,  and  all  other  circumvtances 
are  favourable,  examination  should  always  be  made,  in  order  to  know  whether 
.such  cause  does  not  exist ;  arid  if  it  does,  it  must  be  g-ently  and  carefully 
removed. 


AND  DISLOCATIONS.  279 

treatment,  that  the  discharge  becomes  too  great  for  the  patient  to 
sustain;  and  that,  after  all  the  fatigue,  pain,  and  discipline,  which 
he  has  undergone,  it  becomes  necessary  to  compound  for  life  by 
the  loss  of  the  limb.**  This,  I  say,  does  sometimes  happen  under 
the  best  and  most  rational  treatment;  but  I  am  convinced  that  it 
also  is  now  and  then  the  consequence  of  pursuing  the  reducing,  the 
antiphlogistic,  and  the- relaxing  plan  too  far.  I  would  therefore 
take  the  liberty  seriously  to  advise  the  young  practitioner,  to  attend 
diligently  to  his  patient's  pulse  and  general  state,  as  well  as  to  that 
of  his  fractured  limb  and  wound;  and  when  he  finds  all  febrile 
complaint  at  an  end,  and  all  inflammatory  tumor  and  hardness 
gone,  that  his  patient  is  rather  languid  than  feverish,  that  his  pulse 
is  rather  weak  and  low  than  hard  and  full,  that  his  appetite  begins 
to  fail,  and  that  he  is  inclined  to  sweat  or  purge  without  assignable 
cause,  and  this  in  consequence  of  a  large  discharge  of  matter  from 
a  limb  which  has  suffered  great  inflammation,  but  which  is  now 
become  rather  soft  and  flabby  than  hard  and  tumid;  that  he  will 
in  such  circumstances  set  about  the  support  of  his  patient,  and  the 
strengthening  of  the  diseased  limb,  totis  viribus;  in  which  I  am 
from  experience  satisfied,  he  may  often  be  successful  where  it  may 
not  be  generally  expected  that  he  would.  At  least  he  will  have 
the  satisfaction  of  having  made  a  rational  attempt;  and  if  he  be 
obliged  at  last  to  have  recourse  to  amputation,  he  will  perform  it, 
and  his  patient  will  submit  to  it,  with  less  reluctance  than  if  no 
such  trial  had  been  made. 

I  have  said  that  a  compound  fracture  either  unites  and  heals  as 
it  were  by  the  first  intention,  which  is  the  case  of  some  few,  (and 
was  my  own,)  or  it  is  attended  with  high  inflammation,  multiplied 
abscesses,  and  large  suppuration,  demanding  all  the  surgeon's  atten- 
tion and  skill,  and  even  then  sometimes  ending  in  the  loss  of 
limb,  or  life,  or  both;  or,  that  all  our  attempts  prove  fruitless  frona 

^  There  is  one  circumstance  relative  to  compound  fractures  which  per- 
haps may  be  deemed  worth  noting  ;  wliich  is,  that  I  do  not  remember  ever 
to  have  seen  it  necessary  to  amputate  a  limb  for  a  compound  fracture,  on 
account  of  the  too  great  discharge,  in  which  the  fracture  had  been  united. 
In  all  those  cases,  where  the  operation  has  been  found  necessary  on  account 
■of  the  drain,  the  fracture  has  always  been  perfectly  loose  and  disunited. 


280  REMARKS  ON  FRACTURES 

the  first,  and  gangrene  and  mortification  are  the  inevitable  conse- 
quence of  the  accident. 

The  two  first  I  have  ah-eady  spoken  to — the  last  only  remains. 

Gangrene  and  mortification  are  sometimes  the  inevitable  conse- 
quences of  the  mischief  done  to  the  limb  at  the  time  that  the 
bone  is  broken;  or  they  are  the  consequences  of  the  laceration  of 
parts  made  by  the  mere  protrusion  of  the  said  bone. 

They  are  also  sometimes  the  effect  of  improper  or  negligent 
treatment;  of  great  violence  used  in  making  extension;  of  irrita- 
tion of  the  wounded  parts,  by  poking  after,  or  in  removing  frag- 
ments or  splinters  of  bone;  of  painful  dressings;  of  improper  dis- 
position of  the  limb,  and  of  the  neglect  of  phlebotomy,  anodynes, 
evacuation,  &c.  Any,  or  all  these,  are  capable  either  of  inducing 
such  a  state  of  inflammation  as  shall  end  in  a  gangrene,  or  of  per- 
mitting the  inflammation,  necessarily  attendant  upon  such  acci- 
dent, to  terminate  in  the  same  event. 

When  such  accident  or  such  disease  is  the  mere  consequence  of 
the  injury  done  to  the  limb,  or  produced  by  it  at  the  time  of  frac- 
ture, it  generally  makes  its  appearance  very  early;  in  which  case, 
also,  its  progress  is  generally  too  rapid  for  art  to  check.  For  these 
reasons,  when  the  mischief  seems  to  be  of  such  nature  as  that 
gangrene  and  mortification  are  most  likely  to  ensue,  no  time  can 
be  spared;  and  the  impending  mischief  must  either  be  submitted 
to,  or  prevented  by  early  amputation.  I  have  already  said,  that  a 
very  few  hours  make  all  the  difference  between  probable  safety 
and  destruction.  If  we  wait  till  the  disease  has  taken  possession 
of  the  limb,  even  in  the  smallest  degree,  the  operation  will  serve 
no  purpose,  but  that  of  accelerating  the  patient's  death.  If  we  wait 
for  an  apparent  alteration  in  the  part,  we  shall  have  waited  until 
all  opportunity  of  being  really  serviceable  is  past.  The  disease 
takes  possession  of  the  cellular  membrane  surrounding  the  large 
blood-vessels  and  nerves,  some  time  before  it  makes  any  appear* 
ance  in  the  integuments;  and  will  always  be  found  to  extend 
much  higher  in  the  former  part,  than  its  appearance  in  the  latter 
seems  to  indicate.  I  have  more  tha!n  once  seen  the  experiment 
made  of  amputating,  after  a  gangrene  has  been  begun,  but  I  never 
saw  it  succeed:  it  has  always  hastened  the  patient's  dissolution. 

As  far  therefore  as  my  experience  will  enable  me  to  judge,  or 


AND  DISLOCATIONS.  281 

as  I  may  from  thence  be  permitted  to  dictate,  I  would  advise  that 
such  attempt  should  never  be  made:  but  the  first  opportunity 
having  been  neglected  or  not  embraced,  all  the  power  of  the  chi- 
rurgic  art  is  to  be  employed  in  assisting  nature  to  separate  the  dis- 
eased part  from  the  sound;  an  attempt  which  now  and  I  hen,  under 
particular  circumstances,  has  proved  successful,  but  which  is  so 
rarely  so,  as  not  to  be  much  depended  upon. 

If  the  parts  are  so  bruised  and  torn,  that  the  circulation  through 
them  is  rendered  impracticable,  or  if  the  gangrene  be  the  immediate 
effect  of  such  mischief,  the  consequence  of  omitting  amputation, 
and  of  attempting  to  save  the  limb,  is,  as  I  have  already  observed, 
most  frequently  very  early  destruction:  but  if  the  gangrenous  mis- 
chief be  not  merely  and  immediately  the  effect  of  the  wounded 
state  of  the  parts,  but  of  high  inflammation,  badness  of  general 
habit,  improper  disposition  of  the  limb,  &.c.,  it  is  sometimes  in 
our  power  so  to  alleviate,  correct,  and  alter  these  causes,  as  to  ob- 
tain a  truce  with  the  disease,  and  a  separation  of  the  unsound  parts 
from  the  sound.  The  means  whereby  to  accomplish  this  end,  must, 
in  the  nature  of  things,  be  varied  according  to  the  producing  causes 
or  circumstances:  the  sanguine  and  bilious  must  be  lowered 
and  emptied;  the  weak  and  debilitated  must  be  assisted  by  such 
medicines  as  will  add  force  to  the  visvUm;  and  errors  in  the  treat- 
ment of  the  wound  or  fracture  must  be  corrected:  but  it  is  evident 
to  common  sense,  that  for  these  there  is  no  possibility  of  prescrib- 
ing any  other  than  very  general  rules  indeed.  The  nature  and  cir- 
cumstances of  each  individual  case  must  determine  the  practitio- 
ner's conduct. 

In  general,  inflammation  will  require  phlebotomy  and  an  open 
belly,  together  with  the  neutral  antiphlogistic  medicines;  pain  and 
irritation  will  stand  in  need  of  anodynes  and  the  Peruvian  bark,  join- 
ed in  some  cases  and  at  some  times  with  those  of  the  cooling  kind, 
at  others  with  the  cordial,  will  be  found  necessary  and  useful.  So 
also  tension  and  induration  will  point  out  the  use  of  fomentation 
and  warm  relaxing  cataplasms,  and  the  most  soft  and  lenient  treat- 
ment and  dressing.  But  there  are  two  parts  of  the  treatment  of 
this  kind  of  case  mentioned  by  the  generality  of  writers,  which  I 
cannot  regard  in  the  same  pointof  view  with  then%  One  is,  the 
the  use  of  stimulating  antiseptic  applications  to  the  wound;  the 

VOL.  I.  N  n 


382  REMARKS  ON  FRACTURES 

Other  is,  what  is  commonly  called  scarification  of  the  limb.  [Let 
it  be  remarked  that  I  speak  of  both  these,  as  prescribed  and  prac- 
tised while  the  gangrene  is  forming,  as  it  were,  and  the  parts  are 
by  no  means  mortified.]  While  the  inflammatory  tension  subsists, 
alleviation  of  pain,  and  relaxation  of  the  wound  and  swollen  parts, 
in  order  to  obtain  a  suppuration,  and  conseqnenily  a  separation, 
seem  to  constitute  the  intention,  which  ought  to  be  pursued  upon 
the  most  rational  principles.  Warm  irritaling  tinctures  of 
mvrrh,  aloes,  and  euphorbium;  mixtures  of  tinct.  myrrh,  with 
me!.  iEgyptiac.  and  such  kind  of  medicines,  which  are  found  to 
be  frequently  ordered,  and  indeed  are  frequently  used,  par- 
ticularly in  compound  fractures  produced  by  gun-shot,  seem 
to  me  to  be  very  opposite  to  such  intention,  and  very  little 
likely  to  produce  or  to  contribute  to  the  one  thing  which  ought  to 
be  aimed  at,  I  mean  the  establishment  of  a  kindly  suppuration.  I 
know  what  is  said  in  answer  to  this;  viz.  that  such  kind  of  stimu- 
lus assists  nature  in  throwing  off  the  diseased  parts:  but  this  is  a 
kind  of  language,  which  I  believe  will  be  found  upon  examination 
to  have  been  first  used  without  any  sufficient  or  good  ground,  and 
to  have  been  echoed  ever  since  upon  trust.  It  had  its  foundation 
in  the  opinion  that  gun-shot  wounds  were  poisonous,  and  that  the 
morlifjcaiion  in  them  was  the  eiTect  of  fire,  and  it  has  been  conti- 
nued ever  since,  to  the  great  detrlaient  of  many  a  sufferer.  A  gun- 
shot wound,  whe'iher  with  or  without  fracture,  is  a  wound  accompani- 
ed with  the  highest  degree  of  contusion,  and  with  some  degree  of 
laceration;  and  every  greatly  contused  and  lacerated  wound  re- 
quires the  same  kind  of  treatment  which  a  gun-shot  wound  does, 
as  far  as  regards  the  soft  parts.  The  intention  in  both  ought  to  be 
to  appease  pain,  irritation,  and  inflammation,  to  relax  the  indurat-. 
ed,  and  to  unload  the  swollen  parts,  and  by  such  means  to  procure 
a  kindly  suppuration,  the  consequence  of  which  must  be,  a  sepa- 
ration of  the  diseased  parts  from  the  sound.  Now  whether  this  is 
likely  to  be  best  and  soonest  accomplished  by  such  dressings 
and  such  applications  as  heat  and  stimulate,  and  render  the  parts 
to  which  they  are  applied  crisp  and  rigid,  may  fairly  be  left  to 
common  sense  to  determine. 

Scarification,  in  the  manner  and  at  the  time  in  which  it  is  gene- 
rally ordered  and  performed,  has  never  appeared  to  me  to  have 
served  any  one  good  purpose.  When  the  parts  are  realty  morti- 
fied, incisions  made  of  sufficient  depth  will  give  discharge  to  a 


AND  DISLOGATIONS.  283 

quantity  of  acrid  and  offensive  ichor;  will  let  out  the  confined  air, 
which  is  the  effect  of  putrefaction,  and  thereby  will  contribute  to 
unloading  the  whole  limb;  and  they  will  also  make  way  for  the 
apj)lica(ion  of  proper  dressings.  But  while  a  gangrene  is  impend- 
ing, that  is,  while  the  parts  are  in  the  highest  slate  of  inflammation, 
what  the  benefit  can  be  which  is  supposed  or  expected  to  proceed 
from  scratching  the  surface  of  the  skin  with  a  lancet,  J  never  could 
imagine;  nor,  though  I  have  often  seen  it  practised,  do  I  remem- 
ber ever  to  have  seen  any  real  benefit  from  it.  If  the  skin  be 
still  sound,  and  of  quick  sensation,  the  scratching  it  in  this  super- 
ficial manner  is  painful,  and  adds  io  the  inflamed  state  of  it:  if  it 
be  not  sound,  but  quite  altered,  such  superficial  incision  can  do  no 
possible  service.  Boih  the  sanies  and  the  imp''isoned  air  are  be- 
neath the  membrana  adiposa;  and  merely  scratching  the  skin  in 
the  superficial  manner  in  which  it  is  generally  done,  will  not  reach 
to,  or  discharge  either. 

From  what  has  been  said,  it  will  appear,  that  there  are  three 
points  of  time,  or  three  stages  of  a  bad  compound  fracture,  in 
which  amputation  of  the  limb  may  be  necessary  and  right;  and 
these  three  points  of  time  are  so  limited,  that  a  good  deal  of  the 
hazard  or  safety  of  the  operation  depends  on  the  observance  or 
non-observance  of  them. 

The  first  is  immediately  after  the  accident,  before  inflammation 
has  taken  possession  of  the  parts.  If  this  opportunity  be  neglected 
or  not  embraced,  the  consequence  is  either  a  gangrene  or  a  large 
suppuration,  with  formation  and  lodgement  of  matter.  If  the  former 
of  these  be  the  case,  the  operation  ought  never  to  be  thought  of,  till 
there  is  a  perfect  and  absolute  separation  of  the  mortified  parts. 
If  the  latter,  no  man  can  possibly  propose  the  removal  of  a  limb, 
until  it  be  found,  by  sufficient  trial,  that  there  is  no  prospect  of 
obtaining  a  cure  without,  and  that,  by  not  performing  the  opera- 
lion,  the  patient's  strength  and  life  will  be  exhausted  by  the  dis- 
charge. When  this  becomes  the  hazard,  the  sooner  amputation 
is  performed  the  better.  In  the  first  instance,  the  operation  ought 
to  take  place  before  inflammatory  mischief  is  incurred;  in  the  se- 
cond, we  are  to  wait  for  a  kind  of  crisis  of  such  inflammation;  in 
the  third,  the  proportional  strength  and  state  of  the  patieni,  com- 
pared with  the  discharge  and  state  of  the  fracture,  must  form  our 
determination. 


284  REMARKS  ON  FRACTURES 


*^*  In  my  account  of  the  double  bed,  which  is  mentioned  in  » 
preceding  note,  it  will  be  found  that  it  not  only  is  conducive  to 
cleanliness  and  health,  but  that  it  affords  great  relief  to  both  pa- 
tient and  surgeon  on  many  occasions,  and  is  particularly  interest- 
ing on  the  present  subject  of  compound  frtictures.  In  these  cases, 
as  is  well  known  to  practitioners,  patients  are  often  obliged  to  re- 
main in  their  beds  during  many  months,  while  disunited  iicnes 
and  loose  splinters  cause  inflammation  and  abscesses,  which  fur- 
nish a  discharge  in  such  quantity  as  daily  to  inundate  the  ban- 
dages and  pillows. 

The  necessary  changing  and  renewal  of  these  has  hitherto  been 
done  at  the  expence  of  the  surgeon's  back,  who  in  a  stooping 
painful  posLure  is  obliged  to  support  the  heavy  limb,  often  with  the 
additional  weight  of  splints  and  bandages,  (for  he  dares  not  trust 
it  in  other  hands,)  while  all  the  necessary  apparatus  is  replacing. 
This  must  be  done  by  his  direction;  and  often  in  a  hurry  to  save 
himself,  as  well  as  his  patient,  for  his  fatigue  must  necessarily  in- 
crease every  instant,  his  hands  must  become  unsteady,  and  the 
fractured  bones  will  consequently  be  often  jarred  and  displaced, 
which  cannot  fail  of  bringing  on  fresh  pain  and  inflammation,  and 
retarding  the  cure.  For  fear  of  a  repetition  of  all  this  trouble, 
both  patient  and  surgeon  readily  incline  to  put  off"  the  evil  day  till 
filth  and  putrid  effluvia  make  it  absolutely  necessary  to  be  re- 
newed. 

Whatever  can  tend  to  remedy  or  remove  this  great  inconve- 
nience, must,  I  presume,  be  esteemed  a  valuable  acquisition  by 
all  parlies  concerned — surgeons,  patients,  and  their  attendants ; 
and  I  have  great  pleasure  in  saying  that  this  may  be  eflected  by 
the  double  bed.  The  bar  which  is  added  to  it  reaching  from  head 
to  foot  at  a  proper  height  above  the  bed,  and  the  ends  of  it  turn- 
ing down  and  being  fixed  in  the  two  uprights  which  occasionally 
raise  the  upper  bed,  will  give  a  firm  bearing,  on  which  the  limb 
may  at  any  time  be  suspended  in  a  proper  cradle  or  bandage, 
while  the  nurses  and  attendants  remove  the  dirty  pillows,  cleanse 
the  bed,  and  get  every  thing  ready,  while  the  surgeon  is  prepar- 


AND    DISLOCATIONS.  285 

ing  his  apparatus,  to  replace  it  at  his  leisure,  without  hurrj,  trou- 
ble, or  fatigue. 

This,  though  a  valuable,  is  but  a  secondary  use  of  the  bar;  as  it 
was  originally  intended  to  raise  the  body  of  the  patient,  which 
may  be  slung  on  it  either  by  broad  girths  introduced  under  him; 
or,  if  Ihat  cannot  be  done,  by  the  sheet  on  which  he  lies,  the  cor- 
ners of  it  being  tied  over  the  bar.  The  u])rights  then  being  dis- 
engaged from  their  connexion  with  the  upper  bed,  and  the  handle 
being  turned,  the  bar  will  be  raised  with  the  person  attached  to 
it,  and  the  upper  bed  will  remain,  on  which  may  be  put  fresh 
sheets,  or  what  may  be  wanted:  he  will  then  be  let  down  again, 
and  the  sheet  he  has  used  may  be  drawn  from  under  him;  for  it  is 
easy  to  draw  or  cut  one  away,  though  difficult  to  introduce  a  clean 
one,  while  a  person  is  lying  in  bed. 

Many  o  her  purposes  may  be  served  by  this  bar — for  instance, 
if  there  should  be  a  wound  or  other  complaint  in  the  back,  or 
parts  which  could  not  be  seen  while  the  patient  was  lying  down, 
when  he  is  by  these  means  raised  up,  it  may  be  examined,  and 
applications  made  to  it,  and  other  good  effects  may  be  produced  by 
the  bar,  which  are  noticed  in  the  pamphlet.  When  the  bar  is  not 
wanted,  it  may  be  laid  aside.         E, 


286  REMARKS  ON  FRACTURES 


PLATE  III. 

In  Plate  III.  is  shown  the  bar,  which  has  been  described,  raised  up  and 
reaching  from  head  to  foot:  it  is  fixed  laterally  in  grooves  made  in  the  two 
uprights  which  occasionally  raise  the  upper  bed,  but  in  the  present  view  they 
sire  unconnected  with  it,  and  merely  act  on  the  bar. 

The  dotted  line  marks  how  low  the  bar  may  be  made  to  descend,  in  order 
to  receive  any  weight  which  may  be  attached  to  it,  and  which,  with  a  steady 
smooth  movement,  may  be  raised  to  any  degree,  from  one  inch  to  twenty,  or 
higher  if  required. 


FLATJi  3 


tofrontTaye  28f  Vol.1. 


\ 


AND   DISLOCATIONS.  287 


OF  DISLOCATIONS  IN  GENERAL, 

The  principle  inculcated  so  frequently  in  some  of  the  foregoing 
pages,  concerning  the  extended  or  relaxed,  that  is,  the  resistant 
or  non-resistant  state  of  the  muscles,  as  depending  on  the  posi- 
tion of  the  limb,  may  be  applied  with  equal  truth  and  equal 
advantage  to  dislocations,  as  to  fractures.  Neither  of  them  can 
indeed  be  rightly  understood  or  judiciously  treated  without  such 
consideration.  In  both,  a  perfect  knowledge  of  the  disposition, 
force,  attachments,  and  uses  of  the  muscles,  at  least  those  of  the 
limbs,  are  absolutely  and  indispensably  necessary:  and  if  the 
young  students  would  be  careful  in  attending  to  the  plain  and  obvi- 
ous parts  of  anatomy;  if  they  would  with  their  own  hands  dissect 
the  muscles,  tendons,  blood-vessels  and  nerves;  if  they  would 
examine  minutely  the  structure,  dispositions,  and  connexions  of 
all  the  parts  which  form  the  various  joints,  with  their  ligaments, 
and  attend  to  the  effects  which  the  actions  of  the  muscles  and 
tendons  connected  therewith  must  necessarily  have  on  them,  they 
would  have  much  more  precise  and  adequate  ideas  of  luxations, 
than  many  of  them  have;  they  would  have  ideas  of  their  own,  not 
taken  upon  trust  from  writers,  who  have  for  ages  done  little  more 
than  copy  each  other;  and  they  would  act  with  much  more  satis- 
faction to  themselves. 

By  what  our  forefathers  have  said  on  the  subject  of  luxations, 
and  by  the  descriptions  and  figures  which  they  have  left  us  of  the 
means  they  used,  of  what  they  called  their  organa  and  machine- 
mata,  it  is  plain  that  force  was  their  object,  and  that  whatever 
purposes  were  aimed  at  or  executed  by  these  instruments  or  ma- 
chines, were  aimed  at  and  executed  principally  by  violence. 

Many,  or  most  of  them  indeed,  are  much  more  calculated  to 
pull  a  man's  joints  asunder,  than  to  set  them  to  rights.  I  will 
not  go  so  far  as  to  say,  that  they  are  all  equally  bad  or  improper; 
but  I  will  venture  to  affirm,  that  hardly  any  of  them  are  so  con- 


288  REMARKS  ON  FRACTURES 

trived  as  to  execute  the  purpose  for  which  they  should  be  used,  in  a 
manner  most  agreeable,  or  most  adapted  to  the  nature  or  mecha- 
nism of  the  parts  on  ivhich  they  are  to  operate,  or  to  accomplish 
such  purpose  in  the  most  easy  and  most  practicable  manner;  and 
consequently,  as  1  have  already  said,  they  act  by  force  princi- 
pally. 

Nor  is  that  all:  some  of  them  labour  under  another  defect,  and 
that  capable  of  producing  great  mischief;  which  is,  that  the  force 
or  power  of  the  instrument  is  not  always  determinable,  as  to 
degree,  by  the  operator,  and  consequently  may  do  too  little  or  too 
much,  according  to  different  circumstances  in  the  case,  or  more  or 
less  caution  or  rashness  in  the  surgeon. 

I  know  very  well  that  many  of  these  are  now  laid  aside,  and 
that  some  few  have  been  so  altered,  as  to  become  useful;  but  still 
the  same  kind  of  principle,  on  which  these  inslruments  were  ori- 
ginally founded  and  constructed,  very  generally  prevails,  and 
violence  is  used,  to  the  great  fatigue,  pain,  and  inconvenience  of 
the  patient  in  many  cases,  in  which  dexterity,  joined  to  a 
knowledge  of  the  parts,  would  execute  the  same  purpose  with 
facility  and  ease. 

In  dislocations,  as  in  fractures,  our  great  attention  ought  to  be 
paid  to  the  muscles  belonging  to  the  part  affected.  These  are  the 
moving  powers,  and  by  these  the  joints,  as  well  as  other  moveable 
parts,  are  put  into  action:  while  the  parts  to  be  moved  are  in  right 
order  and  disposition,  their  actions  will  be  regular  and  just,  and 
generally  determinable  by  the  will  of  the  agent  (at  least  in  what 
are  called  voluntary  motions);  but  when  the  said  parts  are  dis- 
turbed from  that  order  and  disposition,  the  action  or  power  of  the 
muscles  does  not  therefore  cease:  far  from  it,  they  still  continue 
to  exert  themselves  occasionally;  but  instead  of  producing  regular 
motions,  at  the  will  of  the  agent,  they  pull  and  distort  the  parts 
they  are  attached  to,  and  which  by  being  displaced  cannot  perform 
the  functions  for  which  they  were  designed. 

From  hence,  and  from  hence  principally,  arise  the  trouble  and 
difficulty  which  attend  the  reduction  of  luxated  joints.  The  mere 
bones  composing  the  articulations,  or  the  mere  connecting  liga- 
ments, would  in  general  afford  very  little  opposition;  and  the  re- 
placing the  dislocation  would  require  very  little  trouble  or  force, 


AND  DISLOCATIONS.  289 

was  it  not  for  the  resistance  of  the  muscles  and  tendons  attached 
to  and  connected  with  them;  for,  by  examining  the  fresh  joints  of 
the  human  body,  we  shall  find  that  they  not  only  are  all  moved 
by  muscles  and  tendons,  but  also,  that  although  what  are  called 
the  ligaments  of  the  joints  do  really  connect  and  hold  them 
togeiher,  in  such  manner  as  could  not  well  be  executed  without 
them,  yet,  in  many  instances,  they  are,  when  stripped  of  all  con- 
nexion, so  very  weak  and  lax,  and  so  dilatable  and  distractile,  that 
they  do  little  more  than  connect  the  bones  and  retain  the  synovia; 
and  that  the  strength,  as  well  as  the  motion  of  the  joints,  depends 
in  great  measure  on  the  muscles  and  tendons  connected  with  and 
passing  over  them;  and  this  in  those  articulations  which  are  de- 
signed for  the  greatest  quantity,  as  well  as  the  celerity  of  motion. 
Hence  it  must  follow,  that  as  the  figure,  mobility,  action,  and 
strength  of  the  principal  joints,  depend  so  much  more  on  the  mus- 
cles and  tendons  in  connexion  with  them,  than  on  their  mere  liga- 
ments; that  the  former  are  the  parts  which  require  our  first  and 
greatest  regard,  these  being  the  parts  which  will  necessarily  oppose 
us  in  our  attempts  for  reduction,  and  whose  resistance  must  be 
either  eluded  or  overcome;  terms  of  very  different  import,  and 
which  every  practitioner  ought  to  be  well  apprised  of. 

From  the  same  examination  is  to  be  obtained  a  kind  and  degree 
of  very  useful  information,  which  the  skeleton  cannot  afford.  I 
mean  an  acquaintance  with  the  ligaments  themselves,  both  ex- 
ternal and  internal;  the  cartilages,  both  fixed  and  moveable;  and 
the  parts  furnishing  what  is  called  the  synovia. 

This,  to  those  who  are  perfectly  acquainted  with  the  subjectj 
may  seem  too  obvious  to  have  needed  mention;  but  no  one  who 
has  not  examined  the  joints  can  possibly  have  this  kind  of  neces- 
sary knowledge;  and  I  am  convinced  that  there  are  many  practi- 
tioners who  have  no  idea  of  articulations,  but  what  the  assemblage 
of  dry  bones  has  furnished  them,  and  which  must  be  very  in- 
adequate. 

I  have  neither  leisure  nor  inclination  at  present  to  enter  into 
this  matter  minutely,  or  indeed  as  it  deserves;  beside  which,  I 
have,  I  fear,  sufficiently  exercised  my  reader's  patience  already  iu 
the  foregoing  sheets.  I  will  therefore  detain  him  no  longer  than 
while  I  mention  a  few  leading  principles  relative  to  luxations  in 

VOL.  I.  0  0 


290  REMARKS  ON  FRACTURES 

general,  drawn  from  ihe  slruclure  of  the  parts  coriceracd,  and 
which  cippear  to  me  to  be  applicable,  with  very  little  if  any  varia- 
tion, to  every  particular  species. 

1.  Although  a  joint  may  have  been  luxated  by  means  of  con- 
siderable violence,  it  does  by  no  means  follow,  that  the  same  de- 
gree of  violence  is  necessary  for  its  reduction. 

2.  When  a  joint  has  been  luxated,  at  least  one  of  the  bones  of 
which  it  is  composed  is  detained  in  that  its  unnatural  situation  by 
the  action  of  some  of  the  muscular  parts  in  connexion  with  it; 
which  action,  by  the  immobility  of  the  joint,  becomes,  as  it  were, 
tonic,  and  is  not  under  the  direction  of  the  will  of  the  patient. 

3.  That  the  mere  bursal  ligaments  of  some  of  the  joints,  endued 
with  great  mobility,  are  weak,  distractile,  and  constantly  moisten- 
ed; that  for  these  reasons  they  are  capable  of  suffering  considera- 
ble violence  without  being  lacerated;  but  that  they  are  also  some- 
times most  certainly  torn. 

4.  That,  did  the  laceration  of  the  said  ligaments  happen  much 
more  frequently  than  I  believe  it  does,  yet  it  cannot  be  a  matter 
of  very  great  consequence,  as  it  neither  totally  prevents  reduction, 
when  timely  and  properly  attempted,  nor  a  consequent  cure.*^ 

5.  That,  supposing  such  accident  to  be  frequent,  yet  as  it  is  im- 
possible to  know,  with  any  kind  of  certainty,  whether  it  has  hap- 
pened or  not,  or  in  what  part  of  the  ligament,  it  cannot  be  ad- 

*  In  the  accident  of  a  dislocated  tibia,  in  consequence  of  a  broken  fibula, 
the  strong,  inelastic,  tendinous  ligaments,  which  fasten  the  end  of  the  former 
bo7ie  to  the  astragalus  and  os  calcis,  are  frequently  torn  ;  and  as  these  by 
proper  care  almost  always  do  well,  and  recover  all  their  strength,  there  is 
the  greatest  reason  to  expect,  that  the  more  weak,  distractile  ones  do  the 
same.  The  only  mischief  which  seems  most  likely  to  follow  from  a  lacerar 
tion  of  the  latter,  is  from  an  effusion  of  the  synovia  ;  of  which  1  think  I  have 
(in  a  bad  habii)  seen  an  instance  in  the  joint  of  the  ancle.  That  the  lacera- 
tion of  the  bursal  ligament  of  tlie  shoulder  cannot  be  a  frequent  or  general 
impediment  to  reduction,  appears  to  me,  from  my  never  having,  in  more  than 
twenty  years'  care  of  an  hvspital,  met  with  a  single  instance  of  its  imprac- 
ticability, when  attempted  in  time. 

For  it  can  hardly  be  supposed,  that  such  kind  of  accident  should  never  have 
fallen  to  my  lot,  or  to  the  people  v/ho  have  acted  under  me. 

But  even  if  this  could  be  supposed,  I  can  also  say,  that  I  do  not  remember 
impossibility  of  reduction  to  have  happened  to  any  of  the  other  gentlemen  of 
the  house,  under  the  same  clrcumslances. 


AND  DISLOCATIONS.  291 

mitted  as  a  rule  for  our  conduct,  nor  ought  such  mere  conjecture 
to  produce  any  deviation  from  what  we  ought  to  do,  were  there  no 
such  supposition.  Could  we  know  with  certainty  when  and  where 
this  had  happened,  very  useful  information  might  indeed  be  drawn 
from  it. 

6.  That  a!l  the  force  used  in  reducin^j  the  luxited  head  of  a 
bone,  be  it  more  or  less,  be  it  by  hands,  towels,  ligature.-,  or  ma- 
chines, ought  always  to  be  applied  to  the  other  extremity  of  the 
said  bone,  and  as  much  as  possible  to  that  only. 

Jn  every  joint  capable  of  dislocation,  the  same  circumstance 
which  renders  it  liable  to  be  displaced,  is  also  a  very  considerable 
assistance  in  its  reduction.  I  mean  the  dilatability  or  distraciile 
power  of  the  ligaments,  their  capacity  of  giving  way  when  stretch- 
ed or  pulled  at. 

This  is  perhaps  the  strongest  argument  which  can  be  produced, 
why  all  the  force  made  use  of  in  reducing  a  dislocated  joint  should 
be  applied  to  that  bone  only,  and  not  to  the  next.  By  the  yielding 
nature  of  the  ligaraenis  of  the  luxated  joint,  reduction  is  to  be  ac- 
complished. The  ligaments  of  the  other  articulation,  which  is 
not  luxated,  are  yielding  also;  and  all  the  force  which  is  applied 
to  the  bone  below  or  adjoining,  must  necessarily  be  lost  in  the 
articulation  which  is  not  luxated,  and  can  be  of  little  or  no  service 
in  that  which  is. 

Let  this  principle  be  applied  to  the  dislocation  of  the  joint  of 
the  shoulder,  and  it  will  shew  us  why  the  ambi,  in  which  the 
whole  arm  is  tied  down,  and  subjected  to  the  extending  power  of 
the  said  instrument,  is  defective,  and  may  be  pernicious.  Why 
instruments  built  on  the  same  general  principle,  but  in  which  the 
fore-arm  is  not  fastened  down,  but  left  at  liberty,  and  not  subjected 
to  the  ligature,  execute  their  purpose  with  a  great  deal  less  force. 
Whythe  vulgar  butfrequently  very  successful  method  of  reducing  this 
joint,  by  placing  the  operator's  heel  in  the  axilla  of  the  supine  pa- 
tient, sometimes  fails,  the  surgeon  not  having  proper  assistance, 
and  contenting  himself  with  pulling  at  the  patient's  wrist  only.  It 
will  also  shew  us,  why,  in  the  case  of  a  luxated  os  femoris  at  the 
joint  of  the  hip,  the  strength  of  five  or  six  people  divided  between 
joint  of  ihe  knee  and  that  of  the  ancle,  shall  be  insufficient;  and 
that  of  four,  nav  three  of  the  same  assistants,  shall  in  the  samjC 


S92  REMARKS  ON  FRACTURES 

case   prove   sufficient,  by  being  all  and  properly  applied  to  the 
knee  and  femur  only,  as  I  have  more  than  once  seen. 

Many  other  applications  of  this  principle  might  be  made,  but 
these  are  sufficient  to  those  who  understand  the  principle  itself  and 
see  its  force. 

7.  That  in  the  reduction  of  such  joints,  as  are  composed  of  a 
round  head,  received  into  a  socket,  such  as  those  of  the  shoulder 
and  hip,  the  whole  body  should  be  kept  as  steady  as  possible,  for 
the  same  reason  as  in  the  foregoing. 

8.  That  in  order  to  make  use  of  an  extending  force  with  all  pos- 
sible advantage,  and  to  excite  thereby  the  least  pain  and  inconve- 
nience, it  is  necessary  that  all  parts  serving  to  the  motion  of  the 
dislocated  joint,  or  in  any  degree  connected  with  it,  be  put  into 
such  a  state  as  to  give  the  smallest  possible  degree  of  resistance. 

This  I  take  to  be  the  first  and  great  principle  by  which  a  sur- 
geon ought  to  regulate  his  conduct  in  reducing  luxations.  This  will 
show  us  why  a  knowledge  of  all  the  muscular  and  tendinous  parts, 
acting  upon,  or  in  connexion  with  the  articulations,  is  absolutely 
necessary  for  him  who  would  do  his  business  scientifically,  with 
satisfaction  to  himself  or  with  ease  to  his  patient.  It  will  shew  us, 
that  the  mere  position  of  the  limb  below  the  luxated  joint,  is  what 
must  either  relax  or  make  tense  the  parts  in  connexion  with  that 
joint,  and  consequently  that  posture  is  more  than  half  of  the  busi- 
ness. It  will  shew  us,  why  sometimes  the  luxated  os  humeri  slips 
in,  as  it  were,  of  its  own  accord,  by  merely  changing  the  position 
of  the  arm,  when  very  violent  attempts,  previous  to  this,  have 
proved  successless.  It  will  shew  us,  why  extending  the  arm  in  a 
straight  line  horizontally,  or  so  as  to  make  a  right  angle  with  the 
body,  must,  in  some  instances,  render  all  moderate  attempts  fruit- 
less. Why  the  method  of  attempting  reduction  by  the  heel  in  the 
axilla  is  so  often  successful,  notwithstanding  two  very  considerable 
disadvantages  under  which  it  labours;  viz.  part  of  the  force  being 
lost  in  the  elbow,  and  the  tense  state  of  one  head  of  the  biceps 
cubiti.  Why  the  tying  down  the  fore-arm  in  the  common  anibi 
is  wrong  for  the  same  reasons.  Why  the  fore-arm  should  at  all 
times,  (let  the  method  of  reduction  be  what  it  may)  be  bent;  viz. 
because  of  the  resistance  of  the  long  head  of  the  biceps  in  an  ex- 
tended posture.     Why,  when  the  os  humeri  is  luxat*"''  forward. 


AND  DISLOCATIONS.  293 

or  so  that  its  head  lies  under  the  great  pectoral  muscle,  the  carry- 
ing the  extended  arm  backward,  so  as  to  put  that  muscle  on  the 
stretch,  renders  the  reduclion  very  difficult;  and  why,  on  the  con- 
trary, the  bringing  the  arm  forward,  so  as  to  relax  the  said  muscle, 
removes  that  difficulty,  and  renders  reduction  easy.  Why  the  re- 
duction of  a  luxated  elbow  should  always  be  attempted  by  bond- 
ing the  said  joint.  Why,  when  the  inner  ancie  is  dislocated  in 
consequence  of  a  fracture  of  the  fibula,  it  is  extremely  difficult  at 
all  times,  and  sometimes  impracticable,  either  to  reduce  or  to  keep 
reduced  the  said  joint,  while  the  leg  is  in  an  extended  posture;  and 
why  a  bent  posture  of  the  leg  enables  us  with  ease  to  accomplish 
both  those  ends.  Why  in  the  case  of  dislocation  of  the  head  of 
the  OS  femoris,  (be  it  in  what  manner  it  may,)  a  straight  position 
of  the  leg  and  thigh  will  always  increase  the  difficulty  of  reduction; 
and  why  that  very  distorted  and  bent  position,  in  which  the  pa- 
tient will  always  place  it  for  his  own  ease,  is  and  must  be  the 
posture  most  favourable  for  reduction;  because  it  is  and  must  be  that 
posture  in  which  the  muscles,  most  likely  to  make  opposition,  are 
most  relaxed,  and  rendered  least  capable  of  resistances 

9.  That  in  the  reduction  of  such  joints  as  consist  of  a  round 
head  moving  in  an  acetabulum  or  socket,  no  attempt  ought  to  be 
made  for  replacing  the  said  head,  until  it  has  by  extension  been 
brought  forth  from  the  place  where  it  is,  and  nearly  to  a  level 
with  the  said  socket. 

This  will  show  us  another  fault  in  the  common  ambl,  and  why 
that  kind  of  ambl,  which  Mr.  Freke  called  his  commander,  is  a 
much  better  instrument  than  any  of  them,  or  indeed  than  all;  be- 
cause it  is  a  lever  joined  to  an  extensor;  and  that  capable  of  being 
used  with  the  arm,  in  such  position  as  to  require  the  least  exten- 

g  In  the  attempts  for  reduction  of  a  luxated  hip,  there  is  one  circumstance, 
which,  by  being  overlooked,  or  not  attended  to,  has  more  than  once  rendered 
every  effort  vain. 

It  is  usual,  and  indeed  necessary,  to  tie  down  and  confine  the  patient  on  a 
bed  or  table,  in  order  to  keep  his  body  firm  and  steady:  one  part  of  the  band- 
age or  strapping  by  which  he  is  confined  is  fixed  in  the  groin,  and,  passing 
over  his  belly  and  under  his  buttock,  is  fastened  above,  or  rather  beyond,  liis 
head,  to  something  immovable.  If  this  bandage  be  placed  (ste  I  have  seen  it) 
in  the  groin  on  the  side  of  the  luxated  bone,  it  will  prove  so  far  from  being 
assistant,  that  it  will  necessarily  frustrate  every  attempt. 


2.94  REMARKS  ON  FRACTURKS 

sion,  antl  to  admit  the  most;  beside  which  it  is  graduated,  and 
therefore  perfectly  under  the  dominion  of  the  operator. 

It  will  show  us,  why  the  old  method  by  the  door  or  ladder 
sometimes  produced  a  fracture  of  the  neck  of  the  scapula,  as  I 
have  seen  it  do  in  our  own  time. 

Why,  if  a  sufficient  degree  of  extension  be  not  made,  the  towel 
over  the  surgeon's  shoulder,  and  under  the  patient's  axilla,  must 
prove  an  impediment  rather  than  an  assistance,  by  thrusting  the 
head  of  the  humerus  under  the  neck  of  the  scapula,  instead  of  di- 
recting it  into  its  socket. 

Why  the  bar  or  rolling-pin  under  the  axilla  produce  the  same 
effect. 

Why  the  common  method  of  bending  the  arm  (that  is,  the  os 
humeri)  downward,  before  sufficient  extension  has  been  made, 
prevents  the  very  thing  aimed  at;  by  pushing  the  head  of  the  bone 
under  the  scapula,  which  the  continuation  of  the  extension  for  a 
few  seconds  only  would  have  carried  into  its  proper  place. 

I  know  it  is  said,  that  mere  extension  only  draws  the  head  of 
the  bone  out  from  the  axilla,  in  which  it  was  lodged,  but  does  not 
replace  it  in  the  acetabulum  scapulae.  To  which  I  uill  venture 
to  answer,  that  when  the  head  of  the  os  humeri  is  drawn  forth 
from  the  axilla,  and  brought  to  a  level  with  the  cup  of  the  scapu- 
la, it  must  be  a  very  great  and  very  unnecessary  addition  of  extend- 
ing force,  that  will  or  can  keep  it  from  going  into  it.  All  that  the 
surgeon  has  to  do  is  to  bring  it  to  such  level:  the  muscles  attached 
to  the  bone  will  do  the  rest  for  him,  and  that  whether  he  will  or 
not. 

Indeed,  if  all  the  rational  means  and  methods  for  reducing  a 
luxated  shoulder  be  examined,  they  will  be  found  to  ac!  upon  this 
principle,  however  differently  ibis  matter  may  appear  to  those 
who  have  not  attended  to  it.  Even  the  common  am!>i  succeeds 
by  means  of  the  extension,  which  the  carrying  ihe  arm  down  with 
it  produces,  and  not  by  its  lever.  That  part  of  the  instrument,  so 
far  from  helping,  is  often  a  considerable  hinderance,  and  even 
sometimes  frnstrates  the  operator's  intention,  by  pushing  the  head 
of  the  bone  ai^ainstthe  scapula,  before  it  is  sufficiently  drawn  out 
from  the  axilla. 

If  it  was  necessary  to  add  any  thing  in  support  of  this  doctrine. 


AND  DISLOGATIONS.  295 

1  should  say,  that  the  supposition  of  laceration  of  the  bursal  liga- 
ment being  a  circumstance  frequently  attending  this  luxaiion,  and 
proving  an  impediment  to  reduction,  is  a  strong  inducement  to  us 
to  be  always  attentive  to  the  making  such  extension,  it  being 
much  more  likely  that  the  head  of  the  bone  should  return  back 
by  the  same  rent  in  the  ligament,  when  such  ligament  is  mode- 
rately stretched  out,  than  when  it  may  be  supposed  to  lie 
ivrinkled  or  in  folds. 

10.  The  last  principle  which  I  shall  take  the  liberty  to  men- 
lion,  and  which  I  would  inculcate  very  seriously,  is,  that  what- 
ever kind  or  degree  of  force  may  be  found  necessary  for  the  re- 
duction of  a  luxated  joint,  that  such  force  be  employed  gradually, 
that  the  less  degree  be  always  first  tried;  and  that  it  be  in- 
creased gradatim. 

Whoever  reflects  on  what  is  intended  by  extension,  what  the 
parts  are  which  resist,  and  how  that  resistance  may  be  best  over- 
come, will  want  little  argument  to  induce  him  to  accede  to  this 
principle;  the  advantages  deducible  from  attending  to  it,  and  the 
disadvantages  ivhich  may  and  do  follow  the  neglect  of  it,  are  so 
obvious. 

They  who  have  not  made  the  experiment  will  not  believe  to 
how  great  a  degree  a  gradually  increased  extension  may  be  car- 
ried without  any  injury  to  the  parts  extended;  whereas  great  force, 
exerted  hastily,  is  productive  of  very  terrible,  and  very  lasting 
mischief. 

I  know  that  the  vis  percussionis,  as  it  is  called,  has  been  re- 
commended as  having  been  successful  in  some  difficult  luxations; 
but  I  have  seen  such  bad  consequences  from  it,  that  I  cannot  help 
bearing  my  testimony  against  it.  The  extensile  and  distractile 
quality  of  the  membranes,  muscles,  and  ligaments,  enables  them 
to  bear  the  application  of  very  great  force  to  them,  without  hurt, 
if  such  force  be  applied  gradually,  and  proper  time  be  allowed 
for  the  parts  to  give  way  in;  but  great  force,  suddenly  applied,  is 
capable  of  producing  the  most  mischievous  consequences;  and 
that  in  many  other  parts  of  surgery,  beside  what  relates  to  luxa- 
tions.^ 

^  I  sliall  take  the  liberty  to  remark  here,  that  in  obstinate  and  difficult  dis- 
locations, the  least  painful  aad  most  effectual  method  of  reducing  them  ap- 


296  REMARKS   ON   FRACTURES,  &C. 

pears  to  me  to  he  by  means  of  a  pulley,  by  which  the  extension  may  be 
madi  in  any  direction  ;  and  the  force  may  be  applied  with  precision,  as  gra- 
4^ually  and  to  as  great  a  degree  as  may  be  thought  necessary,  by  the  assist- 
ance of  one  person  only,  which  is  infinitely  preferable  to  a  number  of  people 
pulling  in  diOerent  directions.  Even  in  an  hospital,  where  there  are  a  sufficient 
number  who  al!  know  what  they  are  about,  and  what  end  is  to  be  answered, 
many  hands  must  pull  irregularly,  as  they  draw  from  different  points;  and 
this  inconvenience  must  be  much  greater  in  private  practice,  where  the  as- 
sistants are  ignorant  and  awkward.  The  patient  may  also  be  kept  more 
firm  and  steady,  by  means  of  a  broad  leathern  belt,  lined  with  soft  flannel, 
which  surrounds  tiie  tiiorax,  and  is  fixed  to  a  post  or  some  immovaole  body, 
than  by  any  number  of  assistants,  making  a  counter  extension.  This  plan,  1  am 
convinced,  is  preferable  to  the  ambi,  or  any  means  1  have  ever  seen  em])loyed 
in  obstinate  cases  of  dislocated  humeri,  and  may  be  applied  very  advanta- 
geously  to  luxations  of  the  os  femoris.  By  the  methods  commonly  in  use, 
the  limbs  are  often  so  bruised  and  excoriated,  that,  if  the  reduction  be  not 
effected  by  the  first,  a  considerable  tinne  is  lost  before  the  inflammation  can 
be  sufficiently  dissipatf  d  to  permit  another  attempt.  The  thick  buff  leather 
T/hich  guards  the  skin  from  the  pressure  of  the  chord  of  the  pulley,  pre- 
vents such  disagreeable  consequences  from  taking  place.        E. 


TREATISE 


RUPTURES. 


XOh.  I.  ?  p 


PREFACE, 

The  disease  which  makes  the  subject  of  the  following  tract,  is 
one  in  which  mankind  are,  on  many  accounts,  much  interested. 
No  age,  sex,  rank,  or  condition  of  life,  is  exempt  from  it;  the  rich, 
the  poor,  the  lazy,  and  the  laborious,  are  equally  liable  to  it;  it 
produces  certain  inconvenience  to  all  who  are  afflicted  by  it;  it 
sometimes  puts  the  life  of  the  patient  in  such  hazard,  as  to  require 
one  of  the  most  delicate  operations  in  surgery;  and  it  has  in  all 
times,  from  the  most  ancient  down  to  the  present,  rendered  those 
who  labour  under  it  subject  to  the  most  iniquitous  frauds  and  im- 
positions. 

The  generality  of  mankind  look  upon  a  rupture  as  an  imper- 
fection in  their  form,  as  a  disease  which  impairs  their  strength, 
and  lessens  their  generative  faculty:  which  apprehensions,  though 
absolutely  groundless,  are  so  firmly  rooted  in  the  majority  of  those 
who  are  afflicted  with  the  disorder,  as  to  make  them  not  a  little 
miserable.  They  who  lie  in  wait  to  avail  themselves  of  the  weak- 
nesses of  the  infirm  and  fearful,  are  well  acquainted  with  these 
fears,  and  very  lucrative  use  do  they  make  of  them.  They  well 
know,  that  the  man  who  regards  his  disorder  as  an  imper- 
fection in  his  form,  or  as  a  cause  of  any  debility,  more  particularly 
a  venereal  one,  will  be  very  unwilling  to  have  it  known,  and  as 
glad  to  get  rid  of  it,  at  any  expense  or  trouble:  by  this  means  these 
impostors  are  furnished  with  opportunities  of  subjecting  the  igno- 
rant and  credulous  to  tedious  confinements,  painful  applications, 


300  PREFACE. 

and  even  hazardous  operations;  and  of  defrauding  the  timorous 
and  bashful  of  large  sums  of  money,  for  imaginary  diseases,  and 
pretended  cures. 

Complaints  of  this  sort,  coming  from  the  profession,  are  gener- 
ally ill  received;  and,  being  set  to  the  account  of  prejudice,  inte- 
rest, and  craft,  are  very  little  regarded;  but  in  this  mankind  do  us 
great  injustice.  A  rupture  is  a  disease,  which,  if  judiciously  and 
honestly  treated  from  the  first,  can  never  be  productive  of  much 
profit  10  a  surgeon;  it  requires  very  little  attendance,  and  neither 
external  application  nor  internal  medicine.  Though  the  reduction 
of  the  gut,  and  the  application  of  a  proper  bandage,  are  necessary, 
yet  ihis  is  in  general  so  soon  and  so  easily  accomplished,  that  it 
must  be  obvious  that  no  great  emolument  can  from  thence  be 
derived;  and  therefore,  if  the  profession  may  be  allowed  to  be 
impartial  in  any  thing  which  relates  to  themselves,  I  think  they 
may  in  this,  from  which  they  never  can  reap  considerable  profit, 
unless  the  disease  has  been  greatly  neglected,  or  ill-treated.  It 
is  from  fraud  and  delusion  principally  that  such  advantage  can  be 
derived;  it  is  from  the  patient's  ignorance  of  the  true  nature  of 
bis  disorder,  and  from  bold  and  lying  promises  m.ade  of  a  perfect 
cure. 

It  is  far  from  my  intention  to  defend  the  body  of  surgeons  from 
any  accusation  which  may  justly  be  brought  against  them;  but 
as  the  reason  given  by  most  of  the  patrons  of  quackery  for  their 
supporting  it,  is,  that  the  medical  world,  through  mere  obstinacy, 
never  depart  from  the  customs  of  their  ancestors,  nor  attempt  any 
thing  niew,  though  mankind  might  be  much  benefitted  by  such  in- 
ventions; and  as  I  think  that  such  imputation  cannot  with  any 
colour  of  justice  be  made  against  us,  I  would  beg  leave  to  be  in- 
dulged a  few  words  on  this  subject. 

That  the  merit  of  many  of  the  old  practitioners  was  great;  that 
they  left  behind  them  many  proofs  both  of  their  sagacity  and  their 


PREFACE.  801 

dexterity;  that  we  have  received  large  information  from  their 
writings;  and  that,  cceteris  paribus^  he  who  is  best  acquainted  with 
them  will  be  the  best  surgeon,  is  well  known  to  every  one  who 
is  at  all  conversant  with  them,  and  can  be  denied  only  by  those 
who  are  not.  But,  on  the  other  hand,  it  must  also  be  allowed, 
that  both  their  theory  and  their  practice  laboured  under  great 
disadvantages,  which  rendered  their  judgment  of  many  diseases 
erroneous,  and  their  treatment  of  them  irrational  and  unsuccessful. 

The  very  imperfect  state  of  their  anatomy  was  one  great  source 
of  error;  which  kind  of  knowledge  has  been  so  cultivated  in  our 
times  as  to  convert  ignorance  into  a  vice,  and  to  render  those 
who  are  deficient  in  it  perfectly  inexcusable. 

As  this  is  the  only  true  and  solid  basis  from  which  all  chirur- 
gical  knowledge  must  for  ever  spring,  so  it  has  of  late  years  been 
productive  of  many  real  and  great  improvements  in  the  art. 

The  ancient  surgery  was  coarse,  and  loaded  with  a  farrago  of 
external  applications,  some  of  which  were  horridly,  and  yet  un- 
necessarily painful,  and  others  altogether  useless;  whilst  the  ope- 
rative part  of  the  art  was  encumbered  with  a  multitude  of  awk- 
ward unmanageable  instruments,  and  pieces  of  machinery. 

The  practitioners  of  the  present  time  have  brought  the  practice 
into  a  much  narrower  compass,  have  rendered  it  less  painful  and 
more  intelligible;  they  have  reduced  the  number  of  instruments, 
and  by  the  extreme  simplicity  of  those  which  they  now  use,  they 
have  considerably  assisted  (he  dexterity  of  an  operator,  and 
shortened  the  time  of  an  operation;  they  have  almost  thrown 
aside  the  burning  cautery,  and  are  much  more  sparing  in  the  use 
of  caustic  applications  than  their  predecessors  used  to  be;  they 
now  accomplish  many  cures  by  mild  and  gentle  means,  which 
formerly  were  thought  not  obtainable  but  by  much  severity;  to 
say  nothing  of  the  indelible  marks  which  such  practice  left  be- 
hind it.     The  havoc  formerly  made  both  of  limbs  and  lives,  by 


302  PREFACE. 

the  use  of  long  forceps  in  gun-shot  wounds;  the  explosion  of  the 
long-prevaiiing  notion  that  such  wound  were  poisonous;  the  easy 
superficial  meuiod  in  which  they  are  now  in  general  treated,  and 
the  opportunities  which  such  treatment  gives  for  nature  to  exert 
those  powers  with  which  the  Ahuighiy  Author  has  furnished  "her, 
do  credit  to  the  modern  practitioners;  the  double  incision  in  am- 
putations; the  present  method  of  removing  cancerous  breasts,  and 
encysted  tumours;  the  lateral  operation  for  the  stone  in  the  blad- 
der; the  use  of  the  cutting  gorget;  amputation  in  the  joint  of  the 
shoulder;  the  present  method  of  letting  out  all  the  water  at  once 
from  an  ascites;  the  impro\emenis  in  the  treatment  of  the  fistula 
lachrjmalis;  the  cure  of  the  vari  and  valgi,  with  many  othere 
which  might  be  named;  in  short,  the  superior  neatness,  ease,  and 
expedition  of  the  present  surgery,  when  compared  to  the  ancient, 
are  certain  and  undoubied  improvements  made  by  the  modern 
practitioners,  and  such  as  mankind  are  much  benefitted  by,  as 
their  pains  are  thereby  lessened,  the  elegance  of  their  figure  pre- 
served, and  the  time  of  their  confinement  shortened;  ail  which 
will,  I  presume,  be  allowed  to  be  advantages,  while  human  na- 
ture shall  remain  sensible  of  pain,  while  scars  shall  be  thought 
deformities,  or  confinement  be  deemed  irksome. 

Nor  is  our  conduct,  with  regard  to  the  particular  disease  which 
makes  the  subject  of  the  following  tract,  in  the  least  degree  blame- 
able;  so  far  from  it,  that  the  treatment  which  we  meet  with  some- 
times is  most  singularly  unjust,  we  being  often  severely  censured 
for  that  from  which  we  ought  to  derive  praise:  so  little  do  we  de- 
serve the  reflection  cast  upon  us,  of  being  content  with  what  our 
fathers  taught  us,  and  neither  improving  the  art  ourselves,  nor 
encouraging  those  who  do:  that,  on  the  contrary,  much  pains  have 
been  taken  to  improve  this  particular  part  of  surgery,  and  the  pub- 
lic ought  to  thank  us  for  not  persevering  in  the  use  of  the  old, 
tedious,  painful,  and  hazardous  processes,  after  we  found  them 
to  be  in  general  ineffectual. 


]fEEPAC£.  303 

But  though  I  would  at  all  times  vindicate  the  profession  from 
€very  unjust  attack.  I  would  by  no  means  be  supposed  to  think 
that  there  is  not  large  room  left  for  the  industry  bo(h  of  us  and 
our  successors;  some  of  the  operative  parts  of  the  art  are  still  ca- 
pable of  improvement,  and  the  treatment  of  some  diseases  might 
certainly  be  altered  for  the  better. 

Whether  our  future  labours  shall  be  crowned  with  success  or 
not,  sfill  I  think  it  will  appear  to  every  one  at  all  versed  in  the 
history  of  surgery,  that  the  practitioners  of  the  present  time  are 
so  far  from  deserving  the  character  which  they  who  know  nothing 
of  the  art  have  given  of  them,  that  they  really  deserve  a  very  con- 
trary one;  since  instead  of  obstinately  adhering  to  the  practice  of 
their  ancestors,  they  have  differed  from  it  in  many  instances, 
where  they  found  they  could  do  it  with  safety,  and  to  the  advan- 
tage of  mankind;  and  have  endeavoured  to  advance  the  utility  of 
their  profession,  by  the  only  means  whereby  it  is  capable  of  being 
improved,  viz.  by  a  sedulous  application  to  anatomy,  by  the  fre- 
quent examinations  of  dead  morbid  bodies,  and  by  making  such 
experiments  on  the  living,  as  they  had  just  reason  to  think  would 
prove  beneficial;  candidly  acknowledging  at  the  same  time,  where 
they  have  found  their  art  insufficient,  and  not  persisting  in  tor- 
menting their  fellow-creatures  merely  for  gain. 

In  the  following  treatise  I  have  endeavoured  to  express  myself 
in  as  plain,'  explicit,  and  intelligible  a  manner  as  f  am  able,  and 
the  subject  will  admit;  being  desirous  as  much  as  I  can  to  inform 
mankind  of  the  true  nature  of  the  disease,  of  the  danger  they  in- 
cur, and  the  frauds  they  are  liable  to,  from  the  ignorance  of  one 
set  of  quacks,  and  the  worse  qualities  of  another:  to  show  what 
the  art  of  surgery  in  judicious  hands  is  capable  of  doing,  and  how 
essentially  the  conduct  of  an  impostor  differs  from  that  of  an  honest 
-man,  who  will  never  be  ashamed  of  confessing  that  he  ran  not  de 
what  is  not  in  his  power. 


304  PREFACE. 

In  the  first  edition  of  this  book  were  many  faults;  some  of 
the  press,  some  of  the  author:  in  this  some  pains  have  been 
taken  to  lessen  both.  Of  typographical  errors  very  few,  if  any, 
will,  I  hope,  be  found;  and  wherever  it  has  appeared  to  me  that 
the  matter  of  the  treatise  was  obscure,  erroneous,  or  deficient,  I 
have  altered,  corrected,  and  added  to  it. 

I  am  still  far  from  thinking  that  it  is  perfect  or  faultless;  but  on 
the  other  hand,  I  am  not  conscious  of  having  advanced  any  thing 
in  it  which  is  not  strictly  true,  and  agreeable  to  the  most  success- 
ful practice.  Improvement  of  the  art  of  surgery,  and  the  relief 
of  mankind,  are  my  two  principal  objects;  and  if  what  I  have 
now,  or  at  any  other  time  written,  shall  be  found  to  have  con- 
tributed toward  accomplishing  either  of  those  ends,  I  hope  the 
reader  will  excuse  all  those  lesser  faults, 

qiias  au'  i:. curia  fudit, 

Aut  humana  parum  cavil  natura. 


A  TREATISE,  &c. 


SECT.  I. 

Bf  the  term  ruphure,  descent,  or  hernia,  is  in  general  meant 
a  swelling  produced  by  the  falling  down  or  protrusion  of  some 
part  or  parts,  which  ought  naturally  to  be  contained  within  the 
cavity  of  the  belly. 

The  places  in  which  these  swellings  make  their  appearance,  in 
order  to  form  what  is  called  a  rupture,  are  the  groin,  the  navel, 
the  labia  pudendi,  the  upper  and  fore  part  of  the  thigh,  and  every 
point  of  the  anterior  part  of  the  abdomen. 

The  parts,  which,  bj  being  thrust  forth  from  the  cavity  in  which 
they  ought  naturally  to  remain,  form  these  tumors,  are  a  portion  of 
the  omentum,  a  part  of  the  intestinal  canal,  and  sometimes*  (though 
very  rarely)  the  stomach. 

From  these  two  circumstances,  of  situation  and  contents,  are 
iJerived  all  the  ditferent  appellations  by  which  herniae  are  dis- 
tinguished: for  example,  they  are  called  inguinal,  scrotal,  ferno- 
'-al,  umbilical,  and  ventral,  as  they  happen  to  make  their  appear- 
ance in  the  groin,  scrotum,  thigh,  navel,  or  belly.  If  a  portion 
of  intestine  only  forms  it,  it  is  called  enterocele,  hernia  intestinalis^ 
or  gut-rupture;  if  a  pi«ce  of  omentum  only,  epiphcele,  hernia  omen- 
talis,  or  caai-rupture;  and  if  both  intestine  and  omentum  conlri- 

»  The  liver,  spleen,  uterus,  bladder,  8;c.  have  at  different  times  been  found 
in  different  hernice.  but  these  are  so  rare  as  not  to  oome  Vv?ithin  a  g^eneral 
description. 

VOL.  T.  Q   q 


306  A  TREATISE  ON  RUPTURES, 

bute  mutually  to  the  formation  of  the  tumor,  it  is  called  enieroepi' 
plocele^  or  compound  rupture. 

If  the  piece  of  gut  or  caul  descends  no  lower  than  the  groin,  it 
is  said  to  be  incomplete,  and  is  called  bubonocele;  if  the  scrotum 
be  occupied  by  either  of  them,  the  rupture  is  said  to  be  complete, 
and  bears  the  name  of  oscheocele:  the  latter  used  by  our  fore- 
fathers to  be  attributed  to  laceration  of  the  peritoneum,  the  former 
to  its  dilatation  merely. 

The  opinion,  that  the  scrotal  hernia  is  occasioned  by  a  forcible 
division,  or  breach  made  in  the  peritoneum,  has  always  been,  and 
still  is,  with  the  unknowing,  a  very  prevailing  one,  though  with- 
out any  foundation  in  truth;  both  the  scrotal  and  femoral  pass  out 
from  the  abdomen  by  openings  which  are  natural  to  every  human 
body;  as  well  those  who  have  not  ruptures,-  as  those  who  have. 
The  former,  that  is  the  scrotal,  descend  by  means  of  an  aperture 
in  the  tendon  of  the  external  oblique  muscle,  near  the  groin;  de- 
signed for  the  passage  of  the  spermatic  vessels  in  men,  and  the 
ligamenta  uteri  in  women;  and  the  latter,  under  the  hollow  made 
by  Poupart's,  or  Fallopius's  ligament,  at  the  upper  part  of  the 
thigh,  along  with  the  great  crural  vein  and  artery. 

The  pair  of  muscles  called  obliqui  externi  ascendentes,  cover  all 
that  part  of  the  belly  which  is  without  bone,  and  the  lower  and 
anterior  parts  of  the  thorax.  They  are  fleshy  on  the  sides,  and 
tendinous  in  the  middle  and  lower  part  ;  they  spring  from  the 
seventh  and  eighth  ribs,  and  from  all  below  them,  by  fleshy  portions 
which  indigiiate  with  corresponding  parts  of  two  other  muscles, 
called  the  serratus  major  anticus,  and  the  latissimus  dorsi,  and 
becoming  tendinous,  are  inserted  into  what  is  called  the  linea 
alba,  the  spine  of  the  os  olium,  and  into  the  os  pubis. 

At  the  lower  part  of  the  belly,  on  each  side,  a  little  above  the 
last  mentioned  bone,  the  fibres  of  the  tejidon  of  this  muscle 
separate  from  each  other,  and  form  thereby  two  apertures,  through 
which  pass  (he  spermatic  vessels  in  men,  and  the  ligamenta  uteri 
in  women.  These  openings  are  of  an  oval  figure,  and  have  an 
fblique  direction  from  above  downward:  the  upper  part  of  them 


A  TREATISE  ON  RUPTURES.  307 

is  rather  wider  than  the  lower,  and  they  are  of  larger  size  in  men 
than  in  women.'* 

The  tendinous  fibres  of  this  muscle,  as  they  proceed  from  its 
fleshy  part  obliquely  downward,  have  several  small  apertures  for 
the  passage  of  vessels  and  nerves;  and  at  their  insertion  into  the 
OS  pubis,  they  cross  one  another,  and  are  as  it  were  interwoven,  by 
which  means  their  insertion  is  strengthened,  and  their  attachment 
made  firmer. 

What  is  called  by  the  particular  name  of  Poupart's  ligament  is 
really  nothing  more  than  the  lower  border  of  this  tendon,  stretch- 
ed from  the  fore  part  of  the  os  ilium,  or  haunch  bone,  to  the 
OS  pubis,  and  turned  or  folded  inward  at  its  interior  edge. 

The  other  muscles  of  the  belly  are  the  obliquus  internus,  the 
transversalis,  the  rectus,  and  the  pyramidalis,  none  of  which  have 
any  concern  with  our  present  subject.  The  spermatic  chord  does 
indeed  pass  under  the  lower  edge  or  border  of  the  two  first  of 
these,  but  at  such  a  distance,  and  in  such  manner,  that  no  action 
©f  these  muscles  can  any  way  affect,  or  ever  make  any  stricture 
either  on  it,  or  on  a  hernia  accompanying  it;  they  have  no  per- 
forations, or  apertures,  though  so  many  writers  of  credit  (even 
late  ones)  have  both  described  and  delineated  them,*^  consequently 

*>  A  detachment  of  fibres  from  the  fascia  lata  of  the  thigh  is  generally 
united  with  the  tendon  composing  the  aperture  in  tiie  obliquus  externus, 
which  mixture  or  connexion  of  fibres  will  in  some  measure  account  for  the 
pain  which  they  who  labour  under  strangulated  ruptures  feel  upon  standing 
upright,  and  the  relief  which  bending  the  tiiigli  upward  toward  the  belly 
always  gives  them. 

•=  However  incredible  and  strange  it  may  seem,  yet  I  am  convinced,  that 
operations  have  been  performed  by  the  information  obtained  from  books  only, 
witliout  any  previous  anatomical  knowledge,  any  practice  on  dead  bodies, 
and  barely  any,  if  any,  opportunities  of  seeing  such  operations  performed  by 
o^Iiers  on  the  living  :  how  grossly  must  such  an  operator  be  deceived  by  the 
account  of  the  rings,  as  they  are  usually,  though  absurdly  called,  of  the  abdo- 
minal muscles:  after  he  has  divided  the  first,  or  that  of  the  external  oblique, 
he  will  expect  to  find  a  second  in  the  internal,  and  a  third  in  the  transversalis, 
and  will  never  suppose  that  he  is  got  into  the  cavity  of  the  belly,  till  he  has 
divided  all  the  three:  it  is  therefore  of  the  utmost  consequence  that  this 
matter  be  set  right,  and  that,  notwithstanding  what  has  been  said  on  this 
subject  by  writers  of  great  eminence,  every  surgeon  be  informed  that  the 
external  oblique  muscle  is  the  only  one  which  hfis  any  opening  in  it;  that  the 


308  A  TREATISE  ON  RUPTURES. 

they  can  have  no  share  in  the  embarrassment  of  the  parts  con- 
tained in  a  hernial  sac,  nor  require  any  division  in  that  operation, 
which  becomes  sometimes  necessary  towards  setting  them  free: 
which  is  a  fact  of  no  small  consequence  to  an  operator. 

The  inside  of  these  muscles,  and  indeed  the  whole  cavity  of 
the  belly,  is  lined  with  a  smooth,  firm,  but  easily  dilatable  mem- 
brane, called  (he  peritoneum,  a  minute  account  of  which  would 
lead  me  beside  my  present  purpose,  and  therefore  I  shall  only 
observe,  that  it  lines  the  whole  abdomen,  and  gives  an  external 
coat  to  every  viscus  contained  in  it. 

Behind  the  peritoneum  lies  a  loose,  cellular  membrane,  by 
some  called  its  appendix,  which  is  ibund  in  different  quantity  in 
different  places.  In  some  the  cells  are  empty,  and  are  immedi- 
ately visible  upon  being  blown  into;  in  other  parts  it  is  plentifully 
stocked  with  fat,  and,  though  somewhat  varied  in  its  appearance 
in  different  places,  is  found  in  most  parts  of  the  body. 

This  cellular  me.mbrane,  void  of  fat,  surrounding  the  sperma- 
tic vessels,  as  they  pass  forth  from  the  cavity  of  the  abdomen  into 
the  groin,  is  called, the  tunica  vaginalis  of  the  chord,  or  tunica 
communis  vasorum  spermaticorum;  which  chord,  thus  enveloped, 
passing  under  the  inferior  edge  or  border  of  the  transversalis,  and 
internal  oblique  muscles,  and  through  the  perforations  or  natural 
apertures  of  the  external  oblique,  descends  through  the  groin  to 
the  testicle,  in  such  manner,  that  the  spermatic  vessels  in  their 
passage  from  the  cavity  are  really  and  truly  behind  the  perito- 
heum. 

The  tunica  vaginalis  testis  is  a  membrane  perfectly  distinct 
from  this,  forming  a  particular  cavity,  which  includes  the  glan- 
dular substance  of  the  testicle,  and  has  nothing  to  do  with  a  com- 
mon rupture.  In  every  foetus,  until,  or  very  near  until  the  time 
of  birth,  there  is  an  open  and  free  communication  between  the 
cavity  of  this  last  tunic,  and  that  of  the  belly,  for  the  passage  of 
the  testicle  from  the  abdomen  into  the  scrotum:  soon  after  birth 

description  given  by  Mr.  Clieselden  of  these  muscles,  in  the  last  edition  of 
his  anatomy,  is  erroneous;  and  all  descriptions  and  all  delineations  (some  of 
which  are  to  be  found  even  in  later  writers)  of  more  openings  than  that 
sinqle  oiie  on  each  side,  are  not  representations  of  nature,  but  are  the  images 
of  a  luxuriant  fancy,  and  have  no  foundation  in  truth. 


A  TREATISE  ON  RUPTURES.  309 

this  passage  closes  and  becomes  impervious;  nor  is  there  ever 
after  the  time  of  such  closing,  any  communication  between  the 
cavity  of  the  belly,  and  that  of  the  tunica  vaginalis  testis.  But 
though  the  passage  remains  in  general  for  ever  shut,  yet  the 
place  where  its  orifice,  or  mouth,  was,  may  always  be  known  by 
a  kind  of  cicatricula,  much  like  to  what  appears  within  the  abdo- 
men, opposite  to  the  navel,  or  place  where  the  umbilical  vessels 
of  the  foetus  passed  to  and  from  the  placenta;  at  the  place  of 
which  cicatricula,  the  peritoneum  is  generally  weaker  than  else- 
where. Now,  if  it  be  remembered,  that  this  weak  part  is  neces- 
sarily opposite  to  the  natural  opening  in  the  tendon  of  the  external 
oblique  muscle;  that  neither  the  internal  oblique  muscle,  nor  the 
transversalis,  comes  low  enough  to  make  any  resistance  to  what- 
ever shall  press  against  this  part;  and  that  the  acknowledged  use 
of  the  muscles  of  the  abdomen  is  by  pressing  on  all  its  contained 
viscera  to  assist  digestion,  the  expulsion  of  the  faeces,  urine,  and 
fcetus;  (and  that  in  many  natural  actions,  such  as  sneezing  and 
coughing,  &c.  and  in  all  great  exertions  of  strength  and  force,  our 
erect  posture  must  necessarily  occasion  a  pressure  to  be  made 
against  the  lower  part  of  the  inside  of  the  belly,  by  some  of  its 
contents;)  a  very  probable  and  satisfactory  account  of  the  origin 
of  the  common  inguinal  and  scrotal  hernia  may  be  collected. 

In  young  children,  this  descent  or  protrusion  happens  most  fre- 
quently when  the  child  strains  in  crying,  or  in  expelling  its  fsces; 
as  soon  as  the  effort  ceases,  and  the  child  is  quiet,  the  part  gene- 
rally returns  up  again,  and  the  swelling  disappears.  The  nurses 
call  it  wind,  and  it  is  at  first  most  frequently  neglected,  as  the 
child  is  not  apparently  injured  by  it,  and  hw  people  are  suffi- 
ciently  aware  of  its  possible  consequences. 

Not  that  the  disease  is  by  any  means  confined  to  children- 
adults  frequently  are  attacked  by  it,  either  by  falls,  strains,  great  ex- 
ertions of  strength,  difficulty  of  expelling  hard  fseces,  or  a  general 
laxi  y  of  frame. 

Whether  the  rupture  be  inguinal,  scrotal,  or  femoral,  and  whe- 
ther it  consists  of  intestine,  or  omentum,  or  both,  the  protruded 
part  must  c  rry  before  it  a  part  of  the  membrane  which  lines  all 
the  internal  surfa.e  of  the  abdominal  muscles,  or  rai  her  the  whole 
cavity  of  the  abdomen,  and  is  called  peritoneum.     This  portion  of 


310  A  TREATISE  ON  RUPTURES. 

the  peritoneum,  including  the  piece  of  gut  or  caul,  is  known  by 
the  name  of  the  hernial  sac,  and  is  larger,  or  smaller,  according  to 
the  quantity  of  intestine,  or  omentum,  contained  in  it:  it  is  at  first 
small  and  thin,  and  in  ruptures  which  are  not  of  the  congenial 
kind,  seldom  comes  lower  than  the  groin'"  at  first,  but  by  repeated 
descents  it  extends  itself  lower  and  lower,  till  it  gets  quite  into 
the  scrotum,  and  still  as  it  is  extended  in  length,  it  becomes 
thickf.T  and  firmer  in  texture,  till  in  old  age,  or  old  ruptures,  it  is 
found  of  very  considerable  thickness. 

As  all  parts  of  the  peritoneum  are  of  a  very  extensible,  di- 
latable nature,  and  as  the  hernial  sac  has  this  property  in  common 
with  many  o'dier  parts  of  the  body,  of  thickening  as  it  extends,  it 
does  in  some  cases  stretch  to  a  very  considerable  size,  and  con- 
tain such  a  quaniity  of  intestine  and  omentum  as  is  almost  incre- 
dible. This  circumstance  of  its  becoming  thicker  as  it  is  more 
extended,  is  perhaps  the  reason  why  some  people,  and  among 
them  the  late  Mr.  Cheselden,  have  been  of  opinion  that  the  sac 
of  a  hernia  was  not  an  elongation  of  the  peritoneum,  but  pro- 
duced like  that  of  an  aneurism,  and  some  other  tumors,  by  mere 
pressure  of  the  common  cellular  membrane;  an  opinion,  which  is 
maniteslly  and  demonstrably  erroneous. 

Whether  the  hernial  sac  in  its  infant  state,  while  it  is  very  thin, 
and  may  possibly  have  contracted  no  adhesion  to  the  cellular 
membrane  composing  the  tunica  communis  of  the  spermatic  ves- 
sels, does  ever  return  back  into  the  belly  again,  I  will  take  upon 
me  to  determine  absolutely;  but  am  much  inclined  to  think  it 
does  not,  as  well  from  the  facility  with  which  the  gut  or  caul 
most  commonly  descends  after  they  have  been  down  a  few  times, 
as  from  a  fulness  which  is  always  to  be  perceived  in  the  sperma- 
tic process  of  such  people  as  have  ever  been  ruptured.  Some  few 
of  these  I  have  had  opportunities  of  opening  after  death,  and  have 
always  found  the  sac,  either  in  the  groin  or  scrotum,  (plainly  a 
continuation  of  ihe  peritoneum,)  remaining  firmly  attached  to,  and 

"^  1  will  not  say  positively  that  all  those  ruptures  which  appear  in  the  scro- 
tum of  very  young  children  are  congenial,  (that  is,  have  the  tunica  vaginalis 
testis  for  their  hernial  sac,)  but  all  those  which  I  have  had  an  oi)portunity  of 
examining  have  proved  so  ;  and  I  believe  it  would  be  no  erro'teous  criterion, 
whereby  to  distinguish  the  common  ruptiu*e  from  the  congenial,  in  infants. 


A  TREATISE  ON  RUPTURES.  311 

connected  with,  the  tunica  communis:  nor  did  I  ever  see,  either 
in  the  dead  or  the  living,  any  reason  or  authority  for  the  supposi- 
tion, that  it  is  capable  of  returning  back  into  the  abdomen  after 
it  has  been  fairly  pushed  out  through  the  aperture  in  the  tendon. « 
I  intentionally  avoid  saying  any  thing  about  the  old  doctrine  of 
the  difference  between  dilatation  and  laceration  of  the  peritoneum, 
it  being  now  generally  known  and  acknowledged,  that  to  what- 
ever size  the  hernial  sac  may  be  extended,  and  however  large  its 
contents  may  be,  it  is  merely  dilated,  and  hardly  ever  burst  or 
broken:  the  particular  kind  of  case,  which  a  few  years  ago  gave 
rise  to  a  sort  of  renewal  of  the  old  doctrine  of  ruptures  by  the  la- 
ceration of  the  hernial  sac,  viz.  that  kind  of  hernia  in  which  the 
gut  and  testicle  are  found  in  the  same  bag,  and  in  immediate  con>- 
tact  with  each  other,  being  now  sufficiently  known  and  explained. 
See  Sec.  X.  of  this  Tract, 


The  signs,  or  marks,  of  a  common  inguinal  or  scrotal  rupture, 
are  in  general  a  swelling  in  the  upper  pan  of  the  scrotum,  or  in 
the  groin,  beginning  at  the  opening  in  the  abdominal  muscles 
where  the  spermatic  vessels  pass  down  from  the  belly;  which  tu- 
mor has  a  different  appearance,  and  different  feel,  according  to 
the  nature  of  its  contents,  and  to  the  state  and  quantity  of  them. 

If  a  portion  of  intestine  forms  it,  and  that  portion  be  small,  the 
tumor  is  small  in  proportion;  but  though  small,  yet  if  the  gut  be 
distended  with  wind,  inflamed,  or  have  any  degree  of  stricture 
made  on  it,  it  w^ill  be  tense,  resist  the  impression  of  the  finger, 

«  This  is  a  circumstance  of  some  impovtance  in  the  general  treatment  of 
ruptures.  Upon  it  depends  the  truth  or  falsehood  of  the  late  doctrine  of  the 
possibility  of  returning  the  intestine  included  in  the  hernial  sac,  and  con, 
fined  by  such  a  stricture  of  the  sac  itself,  as  may  prove  fatal  after  the  gut  is 
fairly  got  into  the  abdomen  again.  A  case,  of  which  more  than  one  instance 
has  been  given  to  us,  but  in  which  I  am  much  inclined  to  believe  that  some 
mistake  has  been  made,  and  which  I  also  think  may  be  accounted  for  in  an- 
other and  more  satisfactory  manner.  Upon  this  also  depends  the  practicability 
or  impracticability  of  returning  a  strangulated  piece  of  gut  back  into  the  beliy, 
after  having  divided  the  stricture  made  by  the  tendon,  without  opening  the 
liernial  sac,  and  consequently  the  propriety  or  impropriety  of  making  sncli 
attempt.  All  endeavours  to  do  what  is  impracticable,  being,  in  cases  of  im- 
portance, much  worse  than  doing  nothing. 


31^  A  TREATISE  ON  RUPTURES. 

and  give  pain  upon  being  handled.  On  the  contrary,  if  there  be 
no  stricture  made  by  the  tendon,  and  the  intestine  suiftrs  no  de- 
gree of  infldmmation,  let  the  prolapsed  piece  be  of  what  length  it 
may,  and  the  tumor  of  whatever  size,  yet  the  tension  will  be  little, 
and  no  pain  will  attend  the  handling  it:  upon  the  patient's  cough- 
ing, it  will  feel  as  if  it  was  blown  into,  and  in  general  it  will  be 
found  very  easily  returnable.  If  the  hernia  be  of  the  omental 
kind,  the  tumor  has  a  more  flabby  and  a  more  unequal  feel:  it  is 
in  general  perfectly  indolent,  is  more  compressible,  gives  the 
scrotum  a  more  oblong  and  less  round  figure,  than  it  bears  in  an 
intestinal  hernia;  and  if  the  quantity  be  large,  and  the  patient 
adult,  it  is  in  some  measure  distinguishable  by  its  greater 
weight. 

If  it  consists  of  both  intestine  and  omentum,  the  characteristic 
marks  will  be  less  clear  than  in  either  of  the  simple  cases,  but 
yet  will  to  any  body  who  is  accustomed  to  these  diseases  be  suffi- 
ciently so,  to  enable  them  to  distinguish  it  from  any  other  com- 
plaint. 

The  only  diseases  with  which  a  true  hernia  can  be  confounded, 
are  the  venereal  bubo^  the  hydrocele,  and  that  defiuxion  on  the  tes- 
ticle, called  hernia  humoralis;  from  each  of  which  it  is  certainly 
very  distinguishable. 

The  circumscribed  incompressible  hardness,  the  situation  of 
the  tumor,  and  its  being  free  from  all  connexion  with  the  sper- 
matic process,  will  sufficiently  point  out  the  firsts  at  least  while  it 
is  in  a  recent  state;  and  when  it  is  in  any  degree  suppurated,  he 
must  have  a  very  small  share  of  the  tactus  eruditus,  who  cannot 
feel  the  difference  between  matter,  and  either  a  piece  of  intestine 
or  omentum. 

The  perfect  equality  of  the  whole  tumor,  the  freedom  and  small- 
ness  of  the  spermatic  process  above  it,  the  power  of  feeling  the 
spermatic  vessels,  and  the  vas  deferens  in  that  process,  its  being 
void  of  pain  upon  being  handled,  the  fluctuation  of  the  watef,  the 
gradual  formaLion  of  the  swelling,  its  having  begun  below  and 
proceeded  upwards,  its  not  being  affected  by  any  posture  or  ac-  . 
tion  of  the  patient,  nor  increased  by  his  coughing  or  sneezings 
together  with  the  absolute  impossibility  of  feeling  the  testicle  at 


A  TREATISE  ON  RUPTURES.  SIB 

the  bottom  of  the  scrotum/  will  always,  to  any  intelligent  person, 
prove  the  disease  to  be  a  hydrocele  of  the  tunica  vaginnlis  testis. 
And  in  the  hernia  humoralis,  the  pain  in  the  testicle,  iis  enlarge- 
ment, the  hardened  slate  of  the  epiiUdinsis,  and  (he  exemption  of 
the  spermatic  chord  from  all  unnatural  fuhiess,  are  such  marks  as 
cannot  easily  be  mistaken:  not  to  mention  the  generally  preceding 
gonorrhea.  But  if  any  doubt  still  remains  of  the  true  nature  of 
the  disease,  the  progress  of  it  from  above  downward,  its  different 
state  and  size  in  different  postures,  particularly  lying  and  stand- 
ing, together  with  its  descent  and  ascent,  will,  if  duly  attended  to, 
put  it  out  of  all  doubt,  that  the  tumor  is  a  true  hernia. 

If  an  attempt  be  made  for  the  reduction  of  the  rupture,  and  it 
consisted  of  a  piece  of  intestine,  it  generally  slips  up  all  at  once. 
In  its  return  it  makes  a  kind  of  guggling  noise;  and  when  it  is  np, 
the  scrotum  and  process  will  be  found  free  from  any  preternatural 
fulness.  If  a  portion  of  omentum  formed  it,  it  retires  more  gra- 
dually, without  any  of  the  noise  of  the  former,  and  requires  to  be 
followed  by  the  finger  to  the  last.  If  both  gut  and  caul  contri- 
buted to  the  formation  of  it,  the  gut  generally  goes  up  first,  and 
leaves  a  flabby  irregular  kind  of  body  behind  it,  which  still  pos- 
sesses the  process  or  scrotum,  according  as  the  disease  was  bu- 
bonocele, or  oscheocele,  and  requiring  still  farther  compression, 
at  last  ascends. 

The  intestine  said  to  be  most  frequently  found  in  a  scrotal  her^ 
nia,  is  the  ileum,  though  it  is  also  allowed  that  the  caecum  and 
part  of  the  colon  have  been  met  with. 

This  is  one  of  the  many  maxims  which  writer  receives  from 
writer,  and  inattentive  readers  all  believe. 

f  By  this  remark  it  may  possibly  be  thought  that  I  mean  to  say,  that  the 
testicle  is  alwajs  to  be  felt  at  the  bottom  of  the  scrotum  in  a  true  hernia; 
which  in  general  is  true,  but  not  without  some  exceptions.  In  recent  rup- 
tures, of  the  common  kind,  whether  of  the  gut  or  caul,  while  the  hernial 
sac  is  tliiii,  has  not  been  long  or  very  much  distended,  and  the  scrotum  still 
preserves  a  regularity  of  figure,  the  testicle  may  almost  always  be  easily  felt 
at  the  inferior  and  posterior  part  of  the  tumor:  but  in  old  ruptures,  which 
have  been  long  down,  in  wliich  the  quantity  of  contents  is  large,  the  sac  con- 
siderably thickened,  and  the  scrotum  of  an  irregular  figure,  it  often  happens 
that  the  testicle  is  not  to  be  felt,  neither  is  it  in  general  easily  felt  in  a  con- 
genial heniia,  for  very  obvious  reasons. 
VOL.    I.  R  r 


314  A  TREATISE  ON  RUPTURES. 

That  a  portion  of  the  ileum  does  often  descend  in  a  hernial  sac 
is  beyond  all  doubt;  but  that  the  descent,  or  more  proper  y  pro- 
perly protrusion,  of  a  part  of  the  caecum  and  colon  is  rare,  is  not 
true,  for  it  happens  very  frequently.  Perhaps  it  would  not  bear 
to  be  established  as  a  general  rule;  but  from  what  has  ftdlen 
within  my  observation,  in  frequently  performing  the  operation  for 
a  strangulated  rupture,  it  has  appeared  to  me,  that  the  greater 
number  of  those  in  whom  it  has  become  necessary,  (all  attempts 
to  reduce  the  parts  by  hand  having  proved  fruitless,)  have  con- 
sisted of  the  caecum  with  its  appendicula,  and  a  portion  of  the  co- 
lon. Nor  will  the  size,  disposition,  and  irregular  figure  of  this 
part  of  the  intestinal  canal,  appear  upon  due  consideration  a  very 
improbable  cause  of  the  difficulty  or  impossibility  of  reduction  by 
the  hand  only. 

I  have  already  mentioned  the  principal  circumstances  by  which 
hernias  are  distinguishable  from  other  diseases.  But  it  is  also 
to  be  observed,  that  the  same  kind  of  rupture  in  different  people, 
and  under  different  circumstances,  wears  a  very  various  face;  the 
age  and  constitution  of  the  subject,  the  date  of  the  disease,  its  be- 
ing free  or  not  free  from  stricture  or  inflammation,  the  symptoms 
"which  attend  it,  and  the  probability  or  improbability  of  its  being 
returnable,  necessarily  producing  much  variety:  the  degree  of 
hazard  attending  this  complaint  will  be  also  more  or  less  as  it 
shall  happen  to  be  circumstanced. 

If  the  subject  be  an  infant,  the  case  is  not  often  attended  with 
much  difficulty  or  hazard;  the  softness  and  ductility  of  their  fibres 
generally  rendering  the  reduction  easy  as  well  as  the  descent; 
and  though  from  neglect  or  inattention  it  may  fall  down  again, 
yet  it  is  as  easily  replaced,  and  seldom  produces  any  mischief:  I 
say  seldom,  because  I  have  seen  an  infant,  one  yeor  old,  die  of  a 
strangulated  hernia,  which  had  not  been  down  two  days,  with  all 
the  symptoms  of  mortified  intestines. 

If  the  patient  be  adult,  and  in  the  vigour  of  life,  the  conse- 
quences of  neglect,  or  of  maltreatment,  are  more  to  be  feared  than 
at  any  other  time,  for  reasons  too  obvious  to  need  relating.  The 
great  and  principal  mischief  to  be  apprehended  in  an  intestinal 
hernia,  is  an  inflammation  of  the  gut,  and  an  obstruction  to  the 
passage  of  the  aliment,  and  faeces  through  it;  which  inflammation 


A  TREATISE  ON  RUPTURES.  315 

and  obstruction  are  generally  produced  by  a  stricture  made  on  the 
intestine,  by  the  borders  of  the  aperture  in  the  tendon  of  the  abdo- 
minal muscle,  through  which  the  hernia  and  its  sac  pass.  Now 
it  must  be  obvious,  that  the  greater  the  natural  strength  of  the  sub- 
ject is  in  general,  and  the  more  liable  to  inflammation,  the  greater 
probability  there  must  be  of  stricture,  and  the  more  mischief  likely 
to  ensue  from  it.  In  very  old  people,  the  symptoms  do  not  usually 
make  such  rapid  progress,  both  on  account  of  the  laxity  of  their 
frame,  and  their  more  languid  circulation;  and  also  that  their 
ruptures  are  most  frequently  of  ancient  date,  and  the  passage  con- 
siderably dilated:  but  then,  on  the  other  hand,  it  should  also  be 
remembered  ihat  they  are  by  no  means  exempt  from  inflammatory 
symptoms;  and  that  if  such  should  come  on,  the  infirmity  of  old 
age  is  no  favourable  circumstance  in  the  treatment  which  may 
become  necessary. 

If  the  disease  be  recent,  and  the  patient  young,  immediate 
reduction,  and  constant  care  to  prevent  its  pushing  out  again,  are 
the  only  means  whereby  it  is  possible  to  obtain  a  perfect  cure. 

If  the  disease  be  of  long  standing,  has  been  neglected,  or  suf- 
fered to  be  frequently  down,  and  has  given  little  or  no  trouble,  the 
aperture  in  the  abdominal  muscle,  and  the  neck  of  the  hernial  sac, 
may  both  be  presumed  to  be  large;  which  circumstances  in  gene- 
ral render  immediate  reduction  less  necessary  and  less  difficult, 
and  also  frustrate  all  rational  expectation  of  a  perfect  cure.  .  On 
the  contrary,  if  the  rupture  be  recent,  or  though  old  has  generally 
been  kept  up,  its  immediate  reduction  is  more  absolutely  neces- 
sary, as  the  risk  of  sU'icture  is  greater  from  the  supposed  smallness 
of  the  aperture,  and  narrowness  of  the  neck  of  the  sac.  If  the 
rupture  be  very  large  and  ancient,  the  patient  far  advanced  in 
life,  the  intestine  not  bound  by  any  degree  of  stricture,  but  does 
its  office  in  the  scrotum  regularly,  and  no  other  inconvenience  be 
found  to  attend  it,  but  what  proceeds  from  its  weight,  it  will  in 
general  be  better  not  to  attempt  reduction,  as  it  will  in  these  cir- 
cumstances most  probably  prove  fruitless,  and  the  handling  of  the 
parts  in  the  attempt  may  so  bruise  and  injure  them  as  to  do  mis- 
chief: but  this  must  be  understood  to  be  spoken,  of  those  only  in 
which  there  is  not  the  smallest  degree  of  stricture,  nor  any  symp- 


31&  A  TREATISE  ON  RUPTURES. 

torn  of  the  obstruction  in  the  intestine;  such  circumstances  making 
reduction  necessary  at  all  times,  and  in  every  ( ase. 

With  regard  to  the  contents  of  a  hernia,  if  it  be  a  portion  of 
omentum  only,  nd  has  been  gradually  formexl,  it  seldom  occasions 
any  bad  symptoms,  though  its  weight  will  sometimes  render  it 
very  troublesome.  But  if  it  be  produced  suddenly  by  effort  or 
violence,  that  is,  if  a  considerable  piece  of  the  caul  by  accident 
slip  down  at  once,  it  will  sometimes  prove  painful,  and  cause  very 
disagreeable  complaints;  the  connexion  between  the  omentum, 
stom  xh,  duodenum,  &c.  being  such  as  to  render  the  sudden 
dL-sccBi  of  a  large  piece  of  the  first  sometimes  productive  of  nausea, 
vomiting,  colic,  and  ail  the  disagreeable  symptoms  arising  from 
the  derangement  of  these  viscera.  When  the  piece  of  caul  is 
engaged  in  such  a  degree  of  stricture  as  to  prevent  the  circulation 
of  blood  through  it,  it  will  sometimes,  by  becoming  gangrenous,  be 
the  occasion  of  very  bad  symptoms,  and  even  of  death,  as  I  have 
more  than  once  seen:  and  thus,  as  a  mere  oraeniai  hernia,  it  may 
sometimes  be  subject  to  great  hazard.  But  even  though  it  should 
never  be  liable  to  the  just  mentioned  evil,  that  is,  though  the  por- 
tion of  the  caul  should  remain  uninjured  in  the  scrotum,  yet  it 
renders  the  patient  constantly  liable  to  hazard  from  another  quar- 
ter: it  makes  it  every  moment  possible  for  a  piece  of  intestine  to 
slip  into  the  same  sac,  and  thereby  add  to  the  case  all  the  trouble 
and  all  the  danger  arising  from  an  intestinal  rupture.  It  is  by  no 
means  an  uncommon  thing  for  a  piece  of  gut  to  be  added  to  a 
rupture,  which  had  for  many  years  been  merely  omental,  and  for 
that  piece  to  be  strangulated,  and  require  immediate  help. 

An  old  omental  hernia  is  often  rendered  not  reducible,  more  by 
an  alteration  made  in  the  state  of  the  prolapsed  piece  of  caul,  than 
by  its  quantity.  It  is  very  common  for  that  part  of  the  omentum 
which  passes  through  the  neck  of  the  sac  to  be  compressed  into  a 
hard,  smooth  body,  and  lose  all  appearance  of  caul,  while  what  is 
below  in  the  scrotum  is  loose  and  expanded,  and  enjoys  its  natural 
texture.  In  this  case  reduction  is  often  impossible,  from  the  mere 
figure  of  the  part;  and  I  have  so  often  seen  this,  both  in  the  living 
and  the  dead,  that  I  am  satisfied,  that  for  one  omental  rupture 
rendered  irreducible  by  adliesions,  many  more  become  so  from  the 
cause  above  mentioned. 


A  TREATISE  ON  RUPTURES.  SH 

In  the  sac  of  old  omental  ruptures  that  have  been  long  down, 
and  only  suspended  by  a  bag  truss,  it  is  no  very  uncommon  thing 
to  have  a  pretty  consiilerable  quantity  of  fluid  collected:  this,  in 
different  states  and  circumstances  of  the  disease,  is  of  different 
colour  and  consistence,  and  seldom  so  much  in  quantity  as  to  oc- 
casion any  particular  attention  to  it;  but  on  the  other  hand,  it 
sometimes  is  so  much  in  quantity  as  to  become  an  additional  dis- 
ease to  the  original  one.  I  have  more  than  once  been  obliged  to 
let  it  out,  in  order  to  remove  the  inconvenience  arising  from  its 
weight,  and  the  distention  of  the  scrotum,  which  I  have  also  seea 
become  gangrenous  by  the  neglect  of  this  operation. 

If  the  hernia  be  of  the  intestinal  kind  merely,  and  the  portion 
of  gut  be  small,  the  risk  is  greater,  strangulation  being  njore  like- 
ly to  happen  in  this  case,  and  more  productive  of  mischief,  when  it 
has  happened:  for  the  smaller  thi?  portion  of  gut  is  which  is  engaged, 
the  tighter  the  tendon  binds,  and  the  more  hazardous  is  the  conse- 
quence. I  have  seen  a  fatal  gangrene,  in  a  bubonocele,  which 
had  not  been  formed  forty-eight  hours,  and  in  which  the  piece 
of  intestine  was  little  more  than  half  an  inch.  There  are  few 
practitioners  who  have  seen  business,  but  know  the  truth  of  this; 
but  perhaps  the  reason  -of  it  is  not  sufficiently  explained  to  the  un- 
knowing. It  is  this:  when  a  considerable  portion  of  intestine 
passes  out  from  the  belly  in  a  hernial  sac,  it  necessarily  and  un- 
avoidably carries  with  it  a  proportional  quantity  of  the  mesentery, 
which  every  body  knows  is  a  strong  doable  membrane.  When 
the  prolapsed  part  is  at  all  considerable,  this  double  membrane  is 
again  in  some  measure  folded  on  itself,  and  lakes  off  a  good  deal 
of  the  effect  of  the  stricture  on  the  intestine.  Now,  although  this 
circumstance  will  not  prevent  the  effect,  if  the  means  of  relief  be 
totally  neglected,  yet  it  will  most  certainly  retard  the  evil,  and 
give  more  time  for  assistance;  whereas,  when  there  is  little 
or  none  of  the  mesentry  got  through  the  tendon,  and  the  thin,  ten- 
der intestine  bears  all  the  force  of  the  stricture,  it  is  immediately 
brought  into  hazard. 

The  practical  inference  to  be  drawn  from  hence  is  loo  obvious 
to  need  mentioning. 

In  the  intestinal,  as  in  ihe  omental  hernia,  they  which  have  been 
often  or  long  down,  are  in  general  more  easily  returned,  and  do 


318  A  TREATISE  ON  RUPTURES. 

not  require  such  immediate  assistance,  as  they  which  hate  seldom 
been  down,  or  have  recently  descended;  and  in  the  one  i<:ind  of 
hernia  as  well  as  the  other,  the  state  of  the  hernial  sac  with  re- 
gard to  size,  thickness,  &c.  depends  very  much  on  the  date  of  the 
disease,  and  the  regard  that  has  been  paid  to  it. 

If  ihe  hernia  be  caused  by  a  portion  of  the  intestine  ileum  only, 
it  is  in  general  more  easily  reducible  than  if  a  part  of  the  colon 
has  descended  with  it,  which  will  also  require  more  address  and 
more  patience  in  the  attempt.  The  reduction  of  a  mere  intestinal 
hernia  loo,  cceleris  paribus,  will  always  remain  more  practicable 
than  that  of  a  mere  ouienlal  one,  after  it  has  attained  to  a  certain 
size  and  state,  as  the  part  contained  within  the  former  is  lia- 
ble to  less  alteration  of  form  than  that  within  the  latter;  which 
alteration  has  already  been  mentioned  as  no  infrequent  hinderance 
of  the  return  of  an  old  caul  rupture. 

Not  that  the  parts  within  a  mere  intestinal  hernia  are  absolute- 
ly exempt  from  such  an  alteration  as  may  render  their  return  in- 
to the  belly  impracticable,  even  where  there  is  no  stricture:  for  I 
have  seen  that  part  of  the  mesentery,  which  has  lain  long  in  the 
neck  of  the  sac  of  an  old  rupture,  so  considerably  hardened  and 
thickened,  as  to  prove  an  insuperable  obstacle  to  its  reduction. 

Upon  the  whole,  every  thing  considered,  I  think  it  may  be  said, 
that  an  intestinal  rupture,  is  subject  to  worse  symptouis,  and  a 
greater  degree  of  hazard  than  an  omental  one,  though  the  latter 
is  by  no  means  so  void  of  either  as  it  is  commonly  supposed  to  be; 
that  bad  symptoms  are  more  likely  to  attend  a  recent  rupture  than 
one  of  ancient  date;  that  the  descent  of  a  very  small  piece  of  in- 
testine is  more  hazardous  than  that  of  a  larger;  that  the  hernia^ 
which  coHsisis  of  gui  on^y,  is  in  general  attended  with  worse  cir- 
cumstances than  thai  which  is  made  up  both  of  gut  and  caul;  and 
that  no  true  judgment  can  be  formed  of  any  rupture  at  all  un- 
less every  circuiv;staiice  resating  to  it  be  taken  into  consideration. 


The  cure  of  a  rupture  is  either  perfect,  (called  also  radical,)  or 
imp<Mlect,  which  is  called  pailiaive. 

This  disiincUon  whi.h  is  jusi  and  true,  and  founded  both  on 
reason  and  experience,  has  frequently  been  misunderstood  by  the 


A  TREATISE  ON  RUPTURES.  319 

generality  of  mankind,  and  has  therefore  been  the  cause  of  much 
undeserved  censure  on  the  practitioners  of  surgery. 

The  truth  is,  that  though  the  events  are  extremely  different,  yet 
the  chirurgi  al  means  which  are  made  use  of  in  either  case  are 
exactly  the  same,  viz.  redciclion  of  the  protruded  parts,  and  reten- 
tion of  them  when  so  reduced  by  proper  bandage:  these  sometimes, 
and  in  some  circumstances,  produce  a  perfect  cure;  at  other  times, 
and  under  other  circumstances  prove  only  a  palliative  one;  and  this 
uncertainty  of  events  being  dependent.on  causes  which  a  surgeon 
can  neither  foresee  nor  direct,  with  any  tolerable  degree  of  cer- 
tainty, should  warn  him  against  being  too  forward  in  making  a 
promise. 

To  those  who  are  ignorant  of  the  anatomical  structure  and  dis- 
position of  the  parts  concerned  in  the  disease,  this  assertion  has 
the  air  of  a  paradox:  they  naturally  suppose  that  the  means  which 
are  or  should  be  made  use  of  to  obtain  a  radical  or  perfect  cure,  are 
or  ought.to  be  different  from  those  used  toward  obtaining  only  a 
palliative  one;  and  in  this  mistake  they  are  confirmed  by  the  bold, 
though  false,  assertions  of  all  rupture-quacks. 

To  labour  under  a  troublesome  disorder,  perhaps  in  the  most 
joyous  and  active  part  of  life,  is  very  disagreeable:  to  be  told  that 
a  palliative  cure,  by  the  constant  use  of  the  truss,  is  all  that  can 
reasonably  be  expected,  gives  small  comfort,  and  renders  the  in- 
sinuation, that  the  regular  professors  of  surgery  do  not  understand 
the  proper  treatment  of  this  disease  credible,  or  at  least  makes  it 
be  believed:  quodvolumus^facik  credimus.  Ignorance  of  the  true 
nature  of  the  disorder,  with  a  strong  desire  to  be  well,  on  the  side 
of  the  patient,  and  bold  plausible  promises  on  the  side  of  the  pre- 
tender, encourage  the  delusion,  till  time,  and  the  continuance  of 
the  rupture,  prove  the  fraud^  which  few  are  found  ingenuous  enough 
to  own.  Whether  it  proceeds  from  a  false  bashfulness,  which 
makes  a  man  be  ashamed  of  acknowledging  that  he  has  been  im- 
posed upon;  from  a  desire  merely  to  conceal  the  disorder;  from 
a  pleasure  arising  from  seeing  others  deceived  as  well  as  them- 
selves; or  from  a  much  worse  cause  than  either  of  these,  I  know 
not:  but  it  happens  not  very  infrequently  that  the  patient,  though 
perfectly  undeceived,  and  convinced  of  the  imposition,  concurs  in 
propagating  the  delusion,  and  asserts  that  he  has  received  a  cure, 
which  he  knows  he  has  not.     Of  this  I  could  produce  many 


S20  A  TREATISE  ON  RUPTURES.  , 

instances,  and  some  of  those  among  people  of  such  rank,  as  one 
would  expect  should  set  them  above  such  disingenuousntiss. 

I  have  already  said,  that  to  replace  the  prolopsed  body,  or 
bjodies,  within  the  cavity  of  the  belly,  and  to  prevent  their  failing 
out  again,  by  means  of  a  proper  bandage,  is  all  that  the  ari  of 
surgery  is  capable  of  doing  in  this  disease:  and  what  I  said  was 
strictly  true.  But  it  must  also  be  remembered,  that  nature,  ac- 
cording to  the  age  of  the  patient,  the  date  of  the  disease,  the  kind 
of  rupture,  and  some  other  circumstances,  is  often  capable  (when 
properly  assisted,  and  not  obstructed)  of  doing  more,  and  of  con- 
firming that  as  a  perfect  cure  in  some,  which  in  others  she  leaves 
imperfect,  and  constantly  requiring  the  assistance  of  art:  for  when 
the  portion  of  gut  or  caul,  or  whatever  formed  the  tumor,  is  per- 
fectly and  properly  replaced  in  the  belly,  and  an  opportunity  there- 
by given  to  the  aperture  in  the  tendon  to  contract  itself,  and  for  a 
proper  bandage  to  bring  the  sides  of  the  entrance  of  the  hernial, 
sac  as  near  together  as  it  will  admit,  the  surgeon  has  really  done 
his  part.  What  remains  is  that  of  nature:  and  whether  she  will 
be  capable  of  so  contracting  the  part,  as  to  prevent  a  future  de- 
scent or  not,  is  matter  of  great  uncertainty:  it  is  a  circumstance 
which  art  has  very  little  power  of  assisting,  and  which  can  be 
known  only  from  the  event. 

On  the  contrary,  all  the  pretensions  which  have  at  difierent 
times  been  made  to  remedies,  indued  with  the  capacity  of  healing 
and  consolidating  the  parts  supposed  to  be  broken  or  torn,  or  of 
constringing  such  as  are  dilated,  have  all  proved  inefficacious  and 
delusive,  to  say  the  best  of  them:  the  parts  concerned  in  this 
disease,  and  which  ought  to  be  affected  by  the  operation  of  such 
remedies,  are  absolutely  out  of  the  reach  of  any  applications  or 
medicines  whatever:  the  relief  which  some  people  have  found 
while  under  such  processes,  has  been  from  the  long  rest  which  they 
have  been  subjected  to,  or  from  the  strict  bandage  which  has  been 
put  upon  them:  either  of  which  will,  in  some  cases,  do  a  great 
deal;  while  the  remedies  which  are  either  applied  or  taken,  are 
made  use  of  merely  to  deceive,  and  never  had,  or  can  have,  any 
share  in  the  real  cure  of  a  rupture. 

By  what  has  been  said,  I  must  beg  not  to  be  understood  to 
mean,  that  when  the  gut  or  caid  have  been  once  replaced,  the 


A  TREATISE  ON  RUPTURES.  321 

patient  can  receive  no  farther  benefit  from  chirurgical  assistance; 
nor  that  every  rupture  in  persons  of  mature  age  is  incapable  of 
perfect  cure:  this  is  far  from  my  meaning,  and  far  from  truth. 
There  are  many  circumstances  attending  ruptures,  which  will 
require  frequent  assistance  in  order  to  render  a  cure  more  pro- 
bable; and  there  are  many  ruptures  in  persons  of  mature  age, 
which  will  admit  of  perfect  cure,  if  properly  and  judiciously 
managed  from  the  first. 

I  only  mean  to  contradict  that  positive  assertion  which  all  rup- 
ture-quacks make  use  of,  and  which  too  many  of  mankind  believe, 
viz.  that  there  are  medicines  and  applications  which  are  specific  in 
the  cure  of. this  disease,  and  that  they  (such  quacks)  are  possessed 
of  them;  both  which  are  absolutely  false. 

As  this  is  a  matter  of  some  impjortance  to  mankind,  and  may 
possibly  be  rendered  still  more  intelligible  by  a  few  words,  I  beg 
leave  to  be  indulged  in  them. 

The  general  doctrine  is,  that  the  ruptures  of  infants,  and  of 
very  young  children,  frequently  admit  of  a  perfect  cure;  those  of 
adults  less  frequently;  and  those  of  old  people  seldom  or  never;  all 
which,  with  certain  limitations,  is  true. 

The  great  and  material  difference  between  these  consists  in  the 
state  of  the  hernial  sac,  and  that  of  the  aperture  in  the  abdominal 
tendon  through  which  it  passes. 

The  sac  of  a  hernia  has  already  been  described  as  being  an 
elongation  or  process  of  the  peritoneum,  or  general  lining  of  the 
cavity  of  the  belly,  thrust  down  before  the  body  constituting  the 
swelling;  which  body  is  enveloped  in  it  as  in  a  bag,  somewhat 
resembling  what  is  vulgarly  called  a  thumb-stall,  or  the  finger  of 
a  glove  cut  off.  While  the  hernia  is  recent,  this  bag  is  thin  and 
fine,  like  the  rest  of  the  membrane  of  which  it  is  a  portion;  and 
being  of  a  very  dilatable  nature,  is  easily  enlarged,  according  to 
the  quantity  of  contents  which  insinuate  themselves  into  it:  like 
some  other  parts  of  the  body,  it  increases  in  thickness  and  tough-  , 
ness  as  it  increases  in  capacity;  and  as  it  seldom  if  ever  returns 
back  into  the  belly,  after  it  has  once  passed  out  from  it,  it  is  by 
the  repeated  descents  of  a  portion  of  gut  or  caul  into  it,  gradually 
enlarged  in  size,  and  consequently  in  thickness;  insomuch,  that 
in  old  ruptures  that  have  been  neglected,  or  deemed  irreducible, 
VOL.  I.  s  s 


3^2 


A  TREATISE  ON  RUPTURES. 


or  been  suffered  to  remain  long,  or  always  down,  it  generally  ac- 
quires a  very  considerable  degree  of  toughness,  thickness,  and 
hardness.  In  those  ruptures  which  are  not  of  the  congenial  kind, 
at  first  it  gets  no  lower  than  the  groin,  and  while  it  remains  there 
is  generally  small  and  thin;  but  by  frequent  protrusions  of  the  in- 
testine or  omentum,  it  is  pushed  by  degrees  into  the  scrotum,  and 
then  most  frequently  acquires  a  pyriform  kind  of  figure,  having 
its  broader  part  in  the  scrotum,  and  its  narrow  one,  or  neck,  in 
the  groin. 

|n  infants,  in  very  young  subjects,  and  in  recent  cases,  this  sac, 
from  its  soft  thin  state,  is  capable  of  having  its  upper  part  or  neck 
So  compressed  by  means  of  a  bandage,  as  either  to  procure  an 
union  of  the  sides  with  each  other,  or  at  least  so  to  lessen  the  dia- 
meter of  its  passage  as  to  prevent  the  descent  of  any  thing  into  it 
from  the  belly:  this  produces  what  is  commonly  called  a  perfect 
cure. 

In  those  of  mature  age,  or  whose  ruptures  are  of  some  stand- 
ing, the  entrance  into  the  sac  is  generally  large,  in  proportion  to 
the  size  and  age  of  the  patient,  and  thicker  and  firmer  than  in  the 
former  state,  for  reasons  just  given:  in  these,  therefore,  the  closing 
or  compression  of  its  neck,  enough  to  hinder  the  falling  down  of 
any  thing  from  the  abdomen,  is  more  difficult  to  accomplish,  and 
more  unlikely  to  succeed.  In  very  ancient  people,  or  very  old 
ruptures,  success  is  still  more  improbable,  for  the  same  reasons. 

A  bandage  therefore,  or  truss,  though  it  is  the  only  remedy  at 
all  ages,  and  in  all  states  of  reducible  ruptures,  yet  acts  in  a  dif- 
ferent manner,  and  is  capable  of  producing  very  different  effects, 
according  to  the  circumstances  of  the  cases  in  which  it  is  applied: 
in  very  young  persons  a  radical  cure  is  frequently  the  conse- 
quence; in  the  middle  aged  it  often  gives  the  tendon  and  mouth 
of  the  sac  such  opportunity  of  being  contracted,  as  to  produce 
nearly  the  same  event;  but  as  it  only  serves  by  the  mere  pressure 
of  the  pad  to  keep  the  parts  in  their  proper  place,  in  very  old 
people  it  can  hardly  ever  be  laid  aside,  without  hazard  of  a  new 
descent,  which,  while  it  is  worn  properly,  it  will  almost  always 
prevent. 

From  the  foregoing  short  account,  the  following  facts  may,  I 
think,  be  collected: — 


A  TREATISE  ON  RUPTURES.  323 

1.  That  the  principal  circumstances  attending  a  rupture  ixiust 
be  subject  to  great  variety,  according  to  the  age  and  constitution 
of  the  patient,  the  date  of  the  disease,  &c.  and  consequently  that 
the  precise  case,  and  age,  in  which  a  radical  or  perfect  cure  is 
obtainable  or  not,  is  not  easy  to  be  determined,  though  a  judicious 
man  will  most  commonly  know  when  it  is  very  improbable. 

2.  That  recent  ruptures,  if  immediately  and  properly  taken 
care  of,  are  capable  of  a  perfect  cure  at  almost  any  age. 

3.  That  though  the  thickness  of  the  hernial  sac,  and  the  large- 
ness of  the  abdominal  aperture,  are  generally  mentioned  as  the 
two  causes  why  old  ruptures  do  not  admit  of  a  cure,  yet  in  fact 
the  latter  is  only  a  consequence  of  the  former. 

4.  That  all  external  applications  in  the  attempt  toward  the 
cure  of  a  rupture,  must,  if  they  are  used  with  any  design  at  all, 
be  intended  eiUier  to  constringe  the  aperture  through  which  the 
parts  have  descended,  or  to  lessen  or  contract  the  diameter  of  the 
neck  of  the  hernial  sac. 

5.  That  the  construction  of  the  tendinous  aperture  (supposing 
such  medicines  could  penetrate  to  it)  is  impossible  while  it  con- 
tinues dilated,  by  an  old,  thick,  tough  hernial  sac,  which  sac,  from 
the  connections  it  always  has-  with  the  cellular  membrane  of  the 
spermatic  chord,  can  never  be  returned  into  the  belly;  and  there- 
fore, 

6.  That  such  medicines  can  be  serviceable  no  other  way  than 
by  rendering  that  sac  again  thin,  fine,  and  compressible;  which, 
from  the  nature  of  things,  and  from  all  experience,  is  absolutely 
impracticable. 


SECT.  II. 


The  different  treatment  which  ruptures  may  require,  being  de- 
pendent on  different  circumstances  attending  the  disease,  I  shall, 
for  the  better  information  of  the  inexperienced  reader,  divide  them 
into  four  classes;  under  which,  I  think,  may  be  comprehended 
not  only  all  the  kinds  of  hernias,  but  every  particularity  also 
with  which  they  may  happen  to  be  distinguished. 


324  A  TREATISE  ON  RUPTURE'S. 

1 .  Under  the  first,  I  reckon  those  which  are  capable  of  easy 
and  immediate  reduction,  and  are  not  attended  by  any  trouble- 
some or  bad  symptoms. 

2.  Under  the  second,  those  which  have  been  so  long  down, 
that  the  contained  parts  are  either  so  altered  in  form,  or  have  con- 
tracted such  adhesions  and  connexions,  as  to  be  absolutely  inca- 
pable of  being  reduced  at  all. 

3.  Under  the  third,  I  comprehend  those  in  which  such  stric- 
ture has  been  made  on  the  protruded  parts,  as  to  bring  on  pain, 
and  produce  such  an  obstruction  in  the  intestinal  canal,  as  to  ren-. 
der  immediate  reduction  necessary,  but  at  the  same  time  difficult. 

4.  And  under  the  fourth,  I  shall  place  those  in  which  the  re- 
turn of  the  parts  by  the  mere  hand  is  absolutely  impracticable, 
and  in  which  the  patient's  life  can  be  saved  only  by  a  chirurgical 
operation. 

The  first  is  very  frequently  met  with  in  infants,  and  sometimes 
in  adults,  and  is  too  often  neglected  in  both.  In  the  former,  as 
the  descent  seldom  happens  but  when  the  infant  strains  to  cry, 
and  the  gut  is  either  easily  put  up,  or  returns  sud  sponte^  as  soon 
as  the  child  becomes  quiet;  it  often  is  either  totally  unattended  to, 
or  an  attempt  made  to  restrain  it  only  by  a  bandage  made  of  cloth 
or  dimity,  and  which,  being  ineffectual  for  siich  purpose,  lays  the 
foundation  for  future  trouble  and  mischief. 

This  is  in  great  measure  owing  to  a  common  opinion,  that  a 
young  infant  cannot  wear  a  steel  truss:  a  generally  prevailing 
error,  and  which  ought  to  be  corrected.  There  is  no  age  at  which 
such  truss  may  not  be  worn,  or  ought  not  to  be  applied;  it  is, 
when  well  made,  and  properly  put  on,  not  only  perfectly  safe  and 
easy,  but  the  only  kind  of  bandage  that  can  be  depended  upon; 
and  as  a  radical  cure  depends  greatly  on  the  thinness  of  the  her- 
nial sac,  and  its  being  capable  of  being  so  compressed  as  possibly 
to  unite,  and  thereby  entirely  close  the  passage  from  the  belly,  it 
must  therefore  appear  to  every  one  who  will  give  himself  the  trou- 
ble of  thinking  on  the  subject,  that  the  fewer  times  the  parts  have 
made  a  descent,  and  the  smaller  and  finer  the  elongation  of  the 
peritoneum  is,  the  greater  the  probability  of  such  cure  must  be. 

The  same  method  of  acting  must  for  the  same  reasons  be  good 
in  every  age  in  which  a  radical  cure  may  reasonably  be  expected; 


A  TREATISE  ON  RUPTURES.  325 

tliat  is,  the  prolapsed  parts  cannot  be  too  soon  returned,  nor  too 
carefully  prevented  from  falling  down  again,  every  new  descent 
rendering  a  cure  both  more  distant  and  more  uncertain. 

As  soon  as  the  parts  are  returned,  the  truss  should  be  imme- 
diately put  on,  and  worn  without  remission,  care  being  taken,  es- 
pecially if  the  patient  be  an  infant,  to  keep  the  parts  on  which  it 
presses  constantly  washed,  to  prevent  galling.^ 

It- can  hardly  be  necessary  to  say  that  the  surgeon  should  be 
careful  to  see  that  the  truss  fits,  as  his  success  and  reputation  de- 
pend on  suchxare.  A  truss  which  does  not  press  enough  is  worse 
than  none  at  all,  as  it  occasions  loss  of  time,  and  deceives  the  pa- 
tient or  his  friends;  and  one  which  presses  too  much,  or  on  an  im- 
proper part,  gives  pain  and  trouble,  by  producing  an  inflamma- 
tion and  swelling  of  the  spermatic  chord,  and  sometimes  of  the 
testicle. 

In  adults,  whose  ruptures  are  of  long  standing,  and  accustomed 
to  frequent  descent,  the  hernial  sac  is  generally  firm  and  thick, 
and  the  aperture  in  the  tendon  of  the  abdominal  muscle  large; 
the  freedom  and  ease  with  which  the  parts  return  into  the  belly, 
when  the  patient  is  in  a  supine  posture,  and  the  little  pain  which 
attends  a  rupture  of  this  kind,  often  render  the  persons  who  la- 
bour under  it  careless:  but  all  such  should  be  informed,  that  they 
are  in  constant  danger  of  such  alteration  in  their  complaint,  as 
may  put  them  into  great  hazard,  and  perhaps  destroy  them.  The 
passage  from  the  belly  being  open,  the  quantity  of  intestine  in  the 

g  As  the  constant  and  unremitted  wearing  a  truss  to  some  people  is  Irksome 
and  inconvenient,  it  may  not  be  improper  to  remark  that  Mr.  Pott  did  not 
Intend  by  the  expression  "  worn  -without  remission,"  that  the  truss  is  always  to 
be  worn,  by  night  as  well  as  by  day ;  he  generally  allowed  it  to  be  taken  off 
when  in  bed,  as  a  recumbent  posture,  in  most  cases,  is  sufficient  security 
against  the  reprotrusion  of  the  intestine  or  omentum  ;  but  the  truss  should 
be  carefully  re-applied  in  the  morning,  while  the  person  is  in  the  same  hori- 
zontal position,  and  either  he,  or  she,  should  be  particularly  observant  to  put 
it  on  when  under  the  necessity  of  going  to  stool  in  the  night.  If  the  patient  be 
subject  to  fits  of  coughing,  common  sense  dictates  that  at  those  times  it  ought 
not  to  be  laid  aside.  Children  are  so  subject  to  violent  exertions  from  crying 
and  other  causes,  that  their  trusses  cannot  often  be  safely  left  ofT;  but  when 
they  are  well  and  quiet,  and  in  bed,  the  pressure  may  now  and  then  be  ju- 
diciously dispensed  with  ;  and  the  removal  of  it,  though  but  for  short  inter- 
vals, affords  them  great  ease  and  relief  E. 


336  A  TREATISE  ON  RUPTURES. 

bernial  sac  is  always  liable  to  be  increased,  and,  when  down,  to 
be  bound  by  a  stricture.  An  inflammation  of  that  portion  of  the 
giit  which  is  down,  or  such  obstruction  in  it  as  may  distend  and 
enlarge  it,  may  at  all  times  produce  such  complaints  as  may  put 
the  life  of  the  patient  into  imminent  danger;  and  therefore,  not- 
withstanding this  kind  of  hernia  may  have  been  borne  for  a  great 
length  of  time,  without  having  proved  either  troublesome  or 
hazardous,  yet,  as  it  is  always  possible  to  become  so,  and  that 
very  suddenly,  it  can  never  be  prudent  or  safe  to  neglect  it. 

Even  though  the  rupture  should  be  of  the  omental  kind,  (which 
considered  abstractedly  is  not  subject  to  that  degree  or  kind  of 
danger  to  which  the  intestinal  is  liable,)  yet  it  may  be  secondarily, 
or  by  accident,  the  cause  of  all  the  same  mischief;  for  while  it  keeps 
the  mouth  of  the  hernial  sac  open,  it  renders  the  descent  of  a 
piece  of  the  intestine  always  possible,  and  consequently  always 
likely  to  produce  the  mischief  which  may  proceed  from  thence. 

They  who  labour  under  a  hernia  thus  circumstanced,  that  is, 
whose  ruptures  have  been  generally  down  while  they  have  been 
in  an  erect  posture,  and  which  have  either  gone  up  of  themselves, 
or  have  been  easily  put  up  in  a  supine  one,  should  be  particularly 
careful  to  have  their  truss  well  made,  and  properly  fitted;  for  the 
mouth  of  the  sac,  and  the  opening  in  the  tendon,  being  both  large 
and  lax,  and  the  parts  having  been  used  to  descend  through  them, 
if  the  pad  of  the  truss  be  not  placed  right,  and  there  be  not  a  due 
degree  of  elasticity  in  the  spring,  a  piece  of  intestine  will,  in  some . 
posture,  slip  down  behind  it,  and  render  the  truss  productive  of 
that  very  kind  of  mischief  which  it  ought  to  prevent. 

It  is  scarcely  credible  how  very  small  an  opening  will  serve 
for  a  portion  of  gut  or  caul  to  insinuate  themselves  into  at  some 
times.  Now,  though  in  persons  of  mature  age  it  most  frequently 
proves  impracticable  so  to  compress  the  mouth  of  the  hernial  sac, 
as  absolutely  to  close  it,  yet,  by  the  constant  use  of  a  well-made 
truss,  it  may  be  so  lessened,  as  to  render  the  descent  of  a  piece  of 
intestine  into  it  much  more  difficult:  from  whence  we  may  learn 
the  great  consequence  of  having  the  part  completely  reduced  be- 
fore the  truss  is  applied,  and  the  danger  that  may  be  incurred  by 
laying  such  bandage  aside  after  it  has  been  worn  some  time;  since 
the  same  alteration  which  renders  the  descent  of  the  gut  less  easy. 


A  TREATISE  ON  RUPTURES.  SS*/ 

will  also  make  the  reduction  more  difFicult,  if  a  piece  sboiikl  hap- 
pen to  get  down:  and  hence  also  we  may  learn  why  the  bandage 
should  be  long  and  unremittingly  worn  by  all  those  whose  time  of 
life  makes  the  expectations  of  a  perfect  cure  reasonable,  many  of 
the  ruptures  of  adults  being  owing  to  the  negligent  manner  in 
which  children  at  school  are  suffered  to  wear  their  trusses. 

I  know  a  gentleman  who  has  for  some  years  had  an  omental 
rupture,  which  was  neglected  while  he  was  young,  and  he  having 
naturally  a  lax  habit,  and  the  abdominal  opening  being  much  di- 
lated, he  finds  it  extremely  difficult  to  keep  it  up,  even  with  the 
best  truss  he  can  get,  behind  which  it  will  sometimes  slip  down: 
when  this  happens,  it  gives  him  such  immediate  and  acute  pain 
at  his  stomach,  and  makes  him  so  intolerably  sick,  that  he  is 
obliged  immediately  to  throw  himself  on  his  back,  and  procure 
the  return  of  the  piece  of  omentum. 


SECT.  III. 


In  the  second  class  I  ranked  those  cases  in  which  the  parts  con- 
stituting the  hernia  are  found  irreducible,  but  not  in  a  state  of  in- 
flammation, nor  producing  any  troublesome  or  dangerous  kind  of 
symptoms. 

This  incapacity  of  reduction  may  be  owing  to  several  causes, 
but  most  frequently  arises  either  from  the  largeness  of  the  quan- 
tity of  the  contents,  from  an  alteration  made  in  their  form  and 
texture,  or  from  connexions  and  adhesions  which  they  have  con- 
tracted with  each  other,  or  with  their  containing  bag. 

I  have  already  mentioned  it  as  my  opinion  that  ruptures  are 
sometimes  rendered  difficult  to  be  reduced,  by  that  portion  of  the 
intestinal  canal  which  is  called  the  caecum,  or  the  beginning  of 
the  colon,  being  contained  in  the  hernial  sac.  Of  which  fact  I 
am  as  much  convinced  as  the  nature  of  such  kind  of  things  will 


328  A  TREATISE  OjST  RUPTURES. 

permit;  that  is,  by  observations  made  both  on  the  living  and  the 
dead. 

When  a  hernia  of  this  kind  {viz.  one  containing  such  a  part  of 
the  intestinal  tube)  has  been  long  neglected,  and  suffered  to 
remain  in  the  scrotum  without  any  bandage  at  all  to  support  its 
weight,  the  hernial  sac,  being  constantly  dragged  down,  and  kept 
in  a  state  of  distention,  necessarily  becomes  thick,  hard,  and 
tough:  by  this  means  the  diameter  of  its  neck  is  lessened,  and  the 
return  of  the  intestine  back  from  the  scrotum  into  the  belly  ren- 
dered more  and  more  difficult,  as  the  parts  through  which  it  is  to 
pass  become  harder,  and  less  capable  of  yielding.  This  will, 
indeed,  in  time  prove  an  obstruction  sufficient  to  hinder  any  part 
of  the  intestine,  or  even  of  the  omentum,  from  being  returned: 
but  the  more  the  difficulty  is,  which  proceeds  from  the  mere 
figure  and  size  of  the  portion  of  gut,  the  greater" will  be  the  ob- 
struction when  added  to  that  arising  from  the  just  mentioned 
cause. 

An  alteration  produced  by  time,  and  constant,  though  gentle, 
pressure  in  the  form  and  consistence,  or  texture  of  the  omentum, 
is  also  no  infrequent  cause,  why  neglected  omental  ruptures  be- 
come irreducible. 

The  cellular  membrane  in  all  parts  of  the  body,  however  loose 
and  light  its  natural  texture  may  be,  is  capable  of  becoming  hard, 
firm,  and  compact,  by  constant  pressure.  Of  this  there  are  so 
many,  and  so  well-known  instances,  that  it  is  quite  unnecessary 
to  produce  any. 

The  omentum,  from  its  texture,  is  liable  to  the  same  conse- 
quence. When  a  portion  of  it  has  been  suffered  to  remain  for  a 
great  length  of  time  in  the  scrotum,  without  having  ever  been 
returned  into  the  belly,  it  often  happens,  that,  although  that  pai't 
of  it  which  is  in  the  lower  part  of  the  hernial  preserves  its  natu- 
ral soft,  adipose,  expansile  state,  yet  all  that  part  which  passes 
through  what  is  called  the  neck  of  the  sac,  is,  by  constant  pressure, 
formed  into  a  hard,  firm,  incompressible,  carnous  kind  of  body, 
incapable  of  being  expanded,  and  taking  the  form  of  the  passage 
in  which  it  is  confined;  exactly  filling  that  passage,  and  rendering 
it  impossible  to  push  up  the  loose  part  which  fills  the  scrotum. 


4.  TREATISE  ON  RUPTURES.  399 

The  same  le.son  ft,-  incapacity  of  reduction  is  also  sometimes 

p.oduccl  „„  il.atpart  of  .l,e  mesenlc-y  which  has  been  suffered  to 
i-  q  .et  or  a  great  length  of  time  in  the  neck  of  an  old  hernial  «, 
1   eot  er  ,mped,men.,  which  1  mentioned,  to  the  re.,,™  of  o  d 

or ,    tHrr"  ""'  ^.'"'^''■'"■"'•*=  P-''^  either  with  each 
,1     i ;.°  ,       '  "'    ""'S  ""'=""'"S  "'™-     I'l'-  i»  co,nmon  to  both 

trr  fte:r\;;,-;:r"^''^      ^"»"'"  ->■ 

iii  cou.aet  „;  h        ,       .'  "'  ''''"  Pe'-»ii'le<l  '0  lie  long 

co.na<,t  only.     These  adhesions  are  more  or  less  fi-m  in 

^tfcent  cases,  but  even  the  slightest  will  almost  ahvas  be  fod 

Many,  or  perhaps  most  of   these  irreducible  ruptures  be-ome 

relief IJ,  '  7'  T  '"'°  ""^  ^'"'^'  *'^  ^^^  capable  of  „o 

scrotLj  '"—.ence  arising  from  the  tveigh.  of  the 

People  in  this  sitaalion  should  be  particularly  careful  not  ,. 
-akea,,yattemp,s  beyond  their  s,re„g.h^orai.„S;:„ 

t:7:::^:^\::;:;-^^^:^  -  -o-d  scr„.um,  a:^ : 
whe,.  the  tumor  is4tgtt:kieT;:::;tst 

^  I  am  not  unaware  that  most  of  these  are  can.M.    r  u  • 
operation  for  the  bubonocele   as  it  :7^!]i  1    T  ^^'''^  ^'"'"^  °J'th« 

p.-oposi„ff  it  in  any  caseTn  vLich  the  '         '        '  "  '  ''""''^  "^^^^-  ^^^"^'^  °f 
life  of  thepatient  so  M^^rn  .  "''  "«^  ^^^^P^^n^s  that  threaten  the 

I  also  a.  nit  una  ^  s  d  Jh.  S""^'  ''  '"  ^^^  P'^^  -  ^  -cans  of  cur., 
sort  has  had  on  theunknolw  u  i^  Vf "'  'P^"^'°"  °^  *^«  ^^  ^^is 
J.ave  emboldened  tiie  me  ope,  a  or  o  c""  "'  "'^^  -cidental  successes 
dors,  in  simibr  cases;  and  that  C  til  .f'  "^^^'^  ^'-" -^  "^"two  mur. 
i-"pture.doclors  h.v  -  ^iVtrStZ  T.  T'  °^  '"'^'"^'  ^^'"^  ^^  '^ese 
han-^ed.  ^    '"^^^-  '^  ^^^^"^'^'^'  «'J^en  they  ought  to  have  beer- 


VOL.  I. 

9  t 


aofl  A,  TKEJTISE  ON  KUPTUKES. 

,vora  at  ll.e  boUom  of  the  cuspemovy  to  prevent  exeorialion,  anci 
le   c  otum  »1.0'<1'1  te  frequently  vvashe.1  for  tl,e  same  r.ason;  a 
s  of  ski,,  i„  this  part,  and  in  sael,  circmstances,  be.ng  some- 
e:„ftl,e.,.,rrost'l,„portance,     Ti«y  o„g„t  also  to    e  paH.c. 
larlv  attentive  to  the  office  of  the  inles.inal  canal,  to  see  Ihat  they 
:,y:    any  irregularity  of  diet  disorcler  it  and  Keept^-clve 
from  being  costive,  for  reasons  too  obv.ous  to  "«'";"  -^^f/, 
these  means,  and  with  these  cautions,  many  FOP'^  '  »  ^ /"^'f, 
their  lives  for  many  years  free  from  d.sease  or  compla.nt,  «,th 
trprv  Invo-p  irreducible  ruptures.  . 

6n  th°e  ler  hand,  it  is  fit  that  mankind  should  be  appr,sed 
thatthe  ,uiet,  inoffens.ve  state  of  thiskind  of  hernia  .  by  no  n.a,. 
to  be  depended  upon;  many  things  may  happen  to  ,t  b    "h   h 
„ay  be  so  altered,  as  to  beconre  haza,-dous,  and  even  fatal,  a,,   , 
flammation  of  that  part  of  the  gut  which  is  down,  any  -^s  ruct^,  to 
ttepassage  of  the  aliment  or  f^ces  through  it,  a  s.ncture  made^ 
b^t     abdominal  tendon,  either  on  what  ha,  been    «»S    ow  , 
on  a  new  portion  which  may  at  any  t,me  be  added  to  .t  a  e  a 
°vays  capable  of  so  altering  the  state  of  the  case,  as  to  put  thehfe 
of  the  patient  into  clanger.  ^ 

ndeed,  the  hazard  arising  from  a  stricture  made  on  a  p.ece  of 
inte  fme   ontained  in  the  sac  of  an  old  irreducible  hernra,  ,s  ,n  one^ 
epg  eater  than  that  attending  one  that  has  bee,,  found  at., me 
due  lie-  since  fro,r.  the  natu,-e  of  the  case  it  w,l    hardly  adm,t 
oftny    tLmpt  toward  relief  but  the  operation,  and  t  a,  ,n  these 
cL^Ltcesmust  necessarily  be  accompanied  w,th  add,t,o„al 

difficulty.* 

T.-.-,rP,1  to  be  i^resent  at  the  opening  of  a  dead  body 
;  I  was  some  time  ago  desired  to  be  pi  c.et.  i,,.educible  lievnia, 

„/ a  man  who  h.d  ibr  many  years  labo.,red  ^  ;;  ^f  '  :,,,  ,.„,  u. 
,ut  .hlch  had  never  ^-^^^^^:X:':^^,:^Zm.o.  permit  me 
weight,  and  who  died  very  old:  m    '^'l^J''}^^'  .entleman,  Mr. 

,0,0,  but  I  desired  leave  ^<^  ^^^^  ^^^^^Z^:^  ^^A;,..  settled  in 
rrice,  who  was  then  my  pupil  at  St.  Ba.tholumcvv^ 

Wales.     The  following  is  the  account  h.  gave  me  :  _^^  ^^^^^^^^ 

..  The  hernia  was  of  fourteen  years  s  andn_,g,  ^"'"^     '"  ^  ,„a  dis- 

I     fr,,.  ;(<;  vprhirlion  :  it  was  on  tne  iigni  si^'<-. 
«had   ever  been   made  foi  '^J'^^^f'""         measured,  from  the  opening  m 
<=  tended    the  scrotum  to  such  a  s,ze,  thaUt  measu, e  ^_^^^  ^^_^ 

»  the  abdominal  muscle  to  the  bottom  of    he  ^    -  '  ^ 0 u  ^^^^  ^^^^ 

.  Ulf.  and  round  the  tumor  ^^^-y^^;;::^':^^:^.,  .„  thick  as  might 

:;;rL:::;:t:s--^-- --  -ie^unumdeum..  sac 


A  TREATISE  ON  RUPTURES.  531 

Among  the  ruptures  which  liave  been  thought  not  reducible, 
and  treated  as  such,  there  have  been  some,  which,  upon  more  judi- 
cious and  more  patient  attempts,  have  been  found  capable  of  re- 
duction. 

When  this  is  suspected  to  be  the  case,  the  proper  method  is  by 
absolute  rest,  in  a  supine  posture,  for  a  considerable  length  of 
lime,  by  great  abstinence,  and  (he  use  of  evacuants,  so  to  lessen 
the  size  of  the  parts  in  the  hernial  sac  as  to  render  them  capable 
of  passing  back  again  into  the  belly. 

This  method  has  now  and  then  succeeded,  and  in  some  cases 
is  worth  the  trying;  but  previous  to  the  attempt,  there  should  be 
some  circumstances  which  makes  success  probable;  and  there 
should  also  be  good  reason  to  believe,  that  the  habit  and  age  of 
the  patient  will  bear  the  necessary  confinement  and  evacuiUion; 
otherwise,  even  though  he  should  get  rid  of  his  rupture,  he  may 
be  much  worsted  by  the  experiment^ 

If  such  attempt  succeeds,  a  truss  should  be  immediately  put  on, 
and  worn  constantly,  without  remission;  for  in  these  people,  the 
largeness  of  the  abdominal  aperture,  the  thickness  of  the  hernial 
sac,  and  the  relaxation  of  the  mesentery,  make  a  new  descent  al- 
ways to  be  apprehended  and  guarded  against. 

An  omental  rupture  which  has  been  so  long  in  the  scrotum  as 
to  have  become  irreducible,  is  very  seldom  attended' with  any 
bad  symptoms,  considered  abstractedly:  but,  as  I  have  already 
said,  it  is  constantly  capable  of  being  the  occasion  of  an  intestinal 
hernia,  and  all  its  consequences;  neither  is  that  aH,  for  the  omen- 

"  of  the  colon,  called  the  cscum,  with  its  apper.dicula  vermiformis,  tog-ether 
"  with  a  Lirge  portion  of  omentum,  were  tlie  contents  ;  the  duodenum  was  so 
"displaced  by  tlie  weiglit  of  the  rest  of  the  guts  within  the  sac,  tiiat  its  direc- 
"  tion  from  the  pylorus  was  perpendicular  ;  the  caul  adhered  to  the  hernial 
"sac in  several  places,  the  intestine  in  none;  the  testicle,  included  in  its  tu- 
"  nica  vaginalis,  was  much  wasted  ;  the  spermatic  artery  and  vein  ran  down 
"  behind  the  hernial  sac,  but  the  vas  deferens  ran  up  on  the  inn.n-  and  left 
"  side  of  it,  at  a  gresit  distance  from  them,  through  the  whole  of  its  course  ; 
"  but  nevertlieless  would  not  have  been  in  the  way  of  the  operation  had  it 
"been  necessary." 

t  Hildanus  gives  an  account  of  a  man  radically  cured  by  six  months'  con- 
finc-mcnt  to  bed,  in  the  case  of  a  rupture  of  twenty  years  date. 

•  Garengeoi  relates  the  case  of  an  epiplocele  producing  very  bad  symptotnS; 
andso  doesDionis. 


332  A  TREATISE  ON  RUPTURESu 

turn,  either  so  altered  in  form  and  texture,  or  so  connected  as  to  be' 
incapable  of  reduction,  may  by  accident  inflame,  and  either  be- 
come gangrenous  or  suppurate,  and  be  the  occasion  of  a  great  deal 
of  trouble.  Of  this  I  have  seen  two  or  three  instances,  one  of 
Tvhich  I  will  relate. 

I  was  desired  to  see  a  gentleman,  from  whose  scrotum  near  a 
pint  of  brown,  sanius,  fceted  fluid  had  been  discharged  two  or  three 
days  before.  The  account  he  gave  of  himself  was  as  follows: 
That  he  had  been  from  his  youth  subject  to  the  descent  of  a  soft, 
flabby  body  into  the  scrotum,  when  he  was  in  an  erect  posture, 
but  which  for  many  years  he  could  put  up  when  he  pleased,  and 
which  always  went  up  when  he  lay  down;  that  having  no  trouble 
from  it,  and  being  naturally  shy  and  bashful,  he  had  done  nothing 
to  it,  nor  showed  it  to  anyone;  that  from  the  sudden  spring  of  an 
unruly  horse,  he  had  struck  it  with  great  violence  against  the  pum- 
mel of  his  saddle,  which  had  given  him  immediate  pain;  that  the 
next  day  it  swelled  still  more,  and  became  more  painful,  but 
that  being  afraid,  or  ashamed,  he  still  concealed  it,  and  only 
anointed  it  with  something  greasy,  till  at  last  he  could  bear  it  no 
longer:  the  person  to  whom  he  showed  it  took  it  for  a  hydrocele, 
tapped  it,  and  let  out  the  fluid  just  mentioned;  and  on  the  fifth  or 
sixih  day  from  this  operation  I  saw  it. 

The  whole  scrotum  was  much  inflamed,  and  the  orifice  made 
by  the  trocar  foul  and  sloughy:  he  had  a  degree  of  heat  and  fever 
upon  him,  which  forbad  any  operation  at  that  time;  and  therefore 
I  desired  that  he  might  be  dressed  soft  and  easy,  have  an  emollient 
cataplasm  applied  to  the  whole  scrotum,  lose  some  blood,  and  have 
a  clyster.  » 

By  proper  care  the  tumor  subsided,  his  fever  left  him,  and  the 
slough  casting  off"  largely  brought  the  putrid  omentum  within  view; 
upon  sight  of  which  I  would  have  laid  the  whole  open,  but  was 
not  permitted.  I  enlarged  the  orifice  a  little,  and  in  so  doing  cut 
through  an  old  hernial  sac,  which  was  very  thick  and  hard;  what 
part  of  the  omentum  was  loose  I  brought  away  with  a  pair  of  for- 
ceps; but  the  separation  of  the  whole  took  up  much  time,  and  the 
bard  hernial  sac  caused  so  many  abscesses,  and  occasioned  so  large 
a  discharge,  that,  being  a  valetudinarian,  he  had  certainly  sunk 
under  it,  had  it  not  been  for  the  free  use  of  the  bark. 


A  TREATISE  ON  RUPTCREa.  33J 

If,  instead  of  this  method  of  treating  it,  I  had  been  permitted  to 
imve  laid  ,t  open  through  the  whole  of  its  length,  r<3moved  the 
roUen  Oinentum,  and  cut  off  some  part  of  the  sides  of  the  hernial 
sac,  the  cure  would  have  been  shortened,  and  the  scrotum,  would 
have  been  left  in  a  much  better  state. 

That  an  omental  rupture,  which  has  so  long  resisted  all  attemp's 
for  reduction,  as  to  create  a  belief  of  its  being  absolutely  irreduci- 
b  e,  maj  now  and  then,  by  long  rest  and  abstinence,  become  capa- 
ble of  bemg  returned,  lam  under  no  doubt,  for  reasons  whirb 
i^ave  already  been  mentioned:  and  not  long  ago,  I  had  myself  a 
patim^t  in  St.  Bartholomew's  hospital,  who  underwent  the  opera- 
tion for  a  radical  cure  of  a  hydrocele,  who  had  also  an  omental 
iierma,  wh.ch  I  and  some  others  had  often  tried  ineffectually  to 
reuuce:  this,  during  the  time  of  his  confinement  to  bed  after  the 
operatmn,  went  up  of  its  own  accord,  and  was  ever  afterwards 
kept  there  by  a  truss. 

It  sometimes  happens  in  old  compound  ruptures,  that  the  piece 
of  mtestme  is  reducible,  and  that  of  the  omentum  is  not;  in  which 
case  we  are  told,  that  the  portion  of  intestine  should  be  kept  up  by 
a  truss  whose  pad  may  be  so  made,  as  not  to  press  on  the  omen- 
turn  whde  it  restrains  the  intestine. 

I  will  not  deny  that  this  may  now  and  then  be  practicable,  but 
It  ,s  not  often  so,  and  it  ought  to  be  particularly  attended  to,  and 
very  carefully  watched,  lest  a  small  piece  of  gut  slip  down,  and 
being  pressed  on  by  the  truss,  produce  fatal  mischief  '        ' 

I  have  seen  an  omental  rupture,  in  which  the  piece  included  In 
the  sac  had  the  knotty  hardness,  the  pain,  and  every  other  svmp- 
torn  of  a  cancer.  *    ' 


SECT.  IV. 

Under  the  third  division  I  reckon  those  ruptures  which  are 
reducible,  but  whose  reduction  is  difficult,  and  which  are  attended 
with  pam  and  trouble  and  hazard. 

^  Difficulty  of  reduction  may  be  owing  to  several  causes.     Thr 
size  of  the  piece  of  omentum,  or  the  inflamed  state  of  it;  the  quaa- 


S34  A  TREATISE  ON  RUPTURES. 

tity  of  intestine  and  mesentery;  an  inflammation  of  the  gut  or  its 
distention  bj  fjEces  or  wind;  or  the  smallness  of  the  aperture  of 
the  tendon  through  which  the  hernia  passes.  But  to  whatever 
cause  it  be  owing,  if  he  prolapsed  body  cannot  be  immediately 
replaced,  and  the  pa.ient  suffers  pain,  or  is  prevented  thereby  from 
going  to  stool,  it  is  called  an  incarcerated  hernia,  a  strangulated 
hernia,  or  a  hernia  with  stricture. 

The  symptoms  are  a  swelling  in  the  groin  or  scrotum,  resisting 
the  impression  of  the  fingers:  if  the  hernia  be  of  the  intestinal 
kind,  it  is  generally  painful  to  the  touch,  and  the  pain  is  increased 
by  coughing,  sneezing,  or  standing  upright.  These  are  the  very 
first  symptoms;  and  if  they  are  not  relieved,  are  soon  followed  by 
others,  viz.  a  sickness  at  the  stomach,  a  frequent  reaching  or  incli- 
nation to  vomit,  a  stoppage  of  all  discharge  per  anum,  attended 
with  a  frequent  hard  pulse,  and  some  degree  of  fever. 

A  patient  in  these  circumstances  may  be  looked  upon  as  in  some 
danger,  and  requiring  immediate  assistance.  A  stricture  made  on 
the  prolapsed  part  of  the  gut,  by  the  borders  of  the  natural  aper- 
ture in  the  tendon  of  the  oblique  muscle,  is  the  immediate  cause 
of  these  symptoms,  which  nothing  can  appease  or  remove,  except 
what  will  take  off  that  stricture.  This  can  be  accomplished  only 
by  removing  the  part  so  bound  from  the  tendinous  opening;  that 
is,  by  returning  it  back  into  the  belly  whence  it  came;  or  by 
dividing  a  part  of  the  tendon  itself:  the  former  of  these,  when  it 
can  be  practised,  is  always  most  eligible,  and  makes  our  present 
subject. 

I  have  already  observed,  that  a  portion  of  intestine,  while  it  is 
neither  bound  by  any  degree  of  stricture,  nor  affected  by  inflam- 
mation, will  remain  quiet  in  a  hernial  sac  in  the  scrotum,  and 
perform  its  proper  office  freely  and  perfectly;  but  the  instant 
either  of  the  above-mentioned  accidents  (particularly  the  former) 
happens,  the  case  is  altered;  the  passage  both  of  the  aliment  and 
fajces  is  stopped  or  interrupted;  the  peristaltic  motion  of  the  whole 
canal  is  disturbed  or  perverted;  and  the  circulation  of  the  blood, 
through  the  straitened  portion  of  intestine,  is  so  imj)eded,  that 
if  the  obstruction  is  not  removed  in  time,  a  mortification  must 
follow. 

Every  symptom  which  attends  an  incarcerated  rupture  depends 


A  TREATISE  ON  RUPTURES.  533 

on  this  cause,  and  is  jusdy  accountable  for  from  it.  The  tumor, 
the  pain,  the  tension  of  the  belly,  tiie  nausea,  the  vomiting,  and 
the  suppression  of  stools,  are  so  many  effects  produced  by  it,  and 
removeable  only  by  removing  it. 

My  present  consideration  being  those  ruptures  which  are  capa- 
ble of  being  returned,  I  am  now  to  speak  of  the  manner  of  at- 
tempting such  reduction. 

The  patient  should  be  laid  in  a  supine  posture,  with  his  trunk 
certainly  as  low,  if  not  lower,  than  his  thighs;  the  thigh  on  the 
diseased  side  should  be  so  elevated,  as  to  contribute  as  much  as 
possible  to  the  relaxation  of  the  abdominal  aperture;  and  then  the 
surgeon  grasping  the  lower  part  of  the  tumor  gently  wiih  his  hand, 
in  such  a  manner  as  to  keep  the  testicle  from  ascending,  and  the 
intestine  from  descending,  must  endeavour  to  procure  the  return 
of  the  latter  through  the  ring,  as  it  is  vulgarly  called,  by  gentle 
continued  pressure  toward  that  opening.  If  the  case  be  a  bubono- 
cele, there  will  be  no  occasion  for  endeavouring  to  grasp  the  tu- 
mor, but  by  continued,  moderate  pressure  on  it  with  the  fingers, 
to  endeavour  the  return  of  the  piece  of  gut. 

This  may  serve  for  a  general  description  of  the  method  of  per- 
forming this  operation;  but  the  exact  manner  of  executing  it  is  one 
of  those  manoeuvres  which  can  be  learnt  only  by  observation  and 
practice,  and  of  which  no  verbal  description  can  convey  an  ade- 
quate and  perfect  idea:  knowledge  of  the  structure  and  situation 
of  the  parts,  will  instruct  any  one  how  to  go  about  it,  and  a  little 
practice  will  soon  make  him  adroit. 

The  posture  of  the  body  and  the  disposition  of  the  lower  limbs 
may  be  made  very  assistant  in  this  operation,  when  the  difficulty 
is  considerable;  the  nearer  the  posture  approaches  to  what  is  com- 
monly called  standing  on  the  head,  the  better,  as  it  causes  the 
whole  packet  of  small  intestines  to  hang,  as  it  were,  by  the  stran- 
gulated portion,  and  may  thereby  disengage  it.  A  little  time  and 
pains  spent  in  (his  manner  will  frequently  be  attended  with  suc- 
cess, and  obtain  a  return  of  the  part;  but  if  it  should  not,  and  the 
handling  of  it  (which  I  must  repeat  should  always  be  gentle)  be- 
comes painful,  and  very  fatiguing  to  the  patient,  we  are  advised 
to  desist  a  fen^  hours,  and  try  the  effect  of  other  means. 


^36  A  TREATISE  ON  RUfTURES. 

These  means  are  phlebotomy,  clysters,  cathartics,  the  applica- 
tion of  cataplasms,  fomentations,  embrocations,  &c. 

Children,  especially  very  young  ones,  bear  the  loss  of  blood 
very  ill,  and  are  very  apt  to  swoon,  if  the  quantity  be  at  all  con- 
siderable; if,  therefore  such  accident  happens,  the  surgeon  should 
embrace  the  opportunity  which  such  general  relaxation  will  afford 
him  of  reducing  the  rupture,  especially  as  it  gives  him  another 
advantage,  by  preventing  the  child  from  crying,  and  making  re- 
sistance. 

Perhaps  there  is  no  dis^ease  affecting  the  human  body  in  which 
bleeding  is  found  more  eminently  and  immediately  serviceable 
than  in  this,  and  which  therefore,  if  there  are  no  particular  cir- 
cumstances in  the  constitution  prohibiting  it,  ought  never  to  bft 
omitted;  but,  on  the  contrary,  should  be  freely  and  largely  re- 
peated, if  it  appears  at  all  necessary. 

A  semicupium,  or  warm  bath,  will,  by  the  general  relaxation 
which  it  necessarily  produces,  be  found  frequently  serviceable. 

The  use  of  warm  fomentations,  soft  cataplasms,  and  relaxing 
oily  embrocations,  are  also  advised  with  a  view  to  relax  the  ten- 
don of  the  abdominal  muscle,  and  to  render  the  return  of  the 
parts  contained  in  the  hernial  sac  easy;  but  I  am  afraid  that  such 
kind  of  applications  have  in  general  been  the  occasion  of  much 
more  mischief  than  good.  The  effect  of  them  can  hardly  reach 
beyond  the  skin  and  membrana  cellularis,  and  may  possibly,  by 
relaxing  them,  take  off  some  small  part  of  the  pain  which  arises 
from  their  distention,  but  will  seldom  have  any  effect  on  the  im- 
mediate seat  of  the  disease,  the  tendon  of  the  oblique  muscle:  the 
enlargement  or  relaxation  of  which  only  can  be  of  material  ser- 
vice. 

I  know  that  in  this  I  differ  from  the  majority  both  of  writers 
and  practitioners,  but  having  (as  I  think)  truth  on  my  side,  I  do 
again  venture  to  say,  that  I  verily  believe,  that  the  confidence 
which  has  been  placed  in  such  kind  of  applications  has  destroyed 
many  more  lives  than  it  has  saved.  A  hernia,  with  painful  stric- 
ture, and  stoppage  of  stools,  is  one  of  those  cases  in  which  we 
can  seldom  stand  still,  even  for  a  short  space  of  time;  if  we  do 
not  get  forward,  we  generally  go  backward;  and  whatever  does 
no  good,  if  it  be  at  nil  depended  upon,  certainly  docs  harm,  by 


A  TREATISE  ON  RUPTURE S%  -337 

occasioning  an  irretrievable  loss  of  time:  of  this  kind  I  take  the 
cataplasm  and  embrocation™  to  be.  While  the  former  is  applied, 
or  the  latter  used,  no  other  more  powerful  means  are  made  use  of; 
and  though  it  has  the  appearance  of  doing  something,  yet  I  fear 
it  is  little  more  than  specious  trifling;  especially  if  the  case  be  at 
all  pressing. 

Very  different  have  been  the  opinions  of  different  people  con- 
cerning the  use  of  cathartic  medicines;  some  advising  them  strenu- 
ously, others  placing  no  dependence  on  them  at  all.  As  different 
also  have  been  the  opinions  of  those  who  do  advise  them,  with 
regard  to  the  kind  of  medicine  proper  on  this  occasion;  some  pre- 
scribing those  of  the  lenient  kind,  such  as  Glauber's  salt,  infusum 
sennae,  &c.  others  the  more  powerful  or  ponderous  kind  of  reme- 
dies, such  as  Extract.  Cathart.  Jallap,  Mercurius  dulcis,'»&c. 

I  believe  I  may  venture  to  say  that  I  have  tried  them  all,  but  I 
cannot  say  that  I  have  such  faith  in  any  of  them  as  to  think  very 
highly  of  them.  With  regard  to  the  former,  viz.  the  lenient  sort 
of  purges,  it  is  not  often  that  a  patient  in  these  circumstances  can 
keep  them  upon  his  stomach;  and  even  when  they  are  not  rejected 
by  vomit,  they  very  seldom  have  force  sufficient  to  answer  the 
end  proposed.  The  more  stimulating  ones  are  certainly  better 
calculated  to  excite  the  peristaltic  motion  of  the  intestines,  (the 
one  thing  to  be  aimed  at,)  and  thereby  free  the  confined  piece;  but 
on  the  other  hand,  if  they  do  not  succeed,  they  add  to  the  fulness 
and  tension  of  the  belly,  as  well  as  to  the  heat  and  thirst. 

I  would  by  no  means  be  understood  to  mean  that  I  am  abso- 
lutely against  the  use  of  cathartic  medicines;  I  only  mean  to 
signify,  that  I  have  no  great  dependence  on  them,  and  that  I  think 

™  In  a  very  pompous  modem  book  may  be  seen  an  operose,  expensive  pro- 
cess, for  makincy  an  ointment  of  a  solution  of  gold,  pearl,  &c.  to  be  used  for 
assisting  the  reduction  of  strangulated  intestines,  and  which,  when  pro- 
perly made,  may  possibly  be  as  useful  as  pomatum,  ointment  of  elder,  or  any 
other  greasy  application. 

"  The  ingenious  and  learned  Dr.  Monro  of  Edinburgh,  says,  that  he  has 
more  than  once  reduced  a  rupture  of  this  kind  by  a  smart  dose  of  jallap  and 
mercurius  dulcis,  when  other  methods  have  failed.  The  same  gentleman  says, 
he  has  seen  the  external  application  of  cold  claret^  or  snow,  instead  of  a  warm 
poultice,  used  with  good  success. 

VOL.  I.  tt  IJ 


33B  A  TREATISE  ON  RUPTURES. 

persisting  in  the  ineffectual  use  of  them  often  adds  unnecessarily 
to  the  suffering  of  the  patient. 

But  though  I  cannot  say  that  I  have  seen  frequent  benefit  from 
the  exhibition  of  cartharlics  by  the  mouth,  yet  I  have  often  ex- 
perienced the  good  arising  from  acrid,  stimulating  clysters,  and- 
suppositories  frequently  repeated;  particularly  from  the  smoke  of 
tobacco"  and  from  a  composition  of  salt,  honey,  and  aloes,  boiled 
to  the  proper  consistence  of  a  suppository.  By  these  I  have  seen 
very  alarming  ruptures  returned,  when  they  have  been  thought 
capable  of  being  relieved  by  nothing  but  the  chirurgical  opera- 
tion. 

There  is  another  method  of  endeavouring  to  obtain  relief  in  this 
case,  which  has  been  proposed  by  few,  and  I  hope  practised  by 
ffewer  (though  I  have  seen  two  patients,  upon  whom  n  had  been 
tried,  and  who  were  both  destroyed  by  it):  it  is  the  making  several 
punctures  with  a  round  needle  through  the  tumid  scrotum  into  the 
gut,  in  order  (as  it  is  said)  to  let  out  the  air  which  is  supposed  to 
distend  the  latter,  and  prevent  its  return.  If  this  practice  was 
worth  a  serious  refutation,  many  arguments,  drawn  from  the 
nature  both  of  the  parts  and  of  the  disease,  might  be  produced 
against  it:  but  it  is  really  too  absurd  to  waste  either  my  own  or  the 
reader's  time  about  it. 

There  is  no  circumstance  attending  ruptures  with  stricture,  in 
which  more  variety  is  found,  than  in  the  time  which  they  will 
safely  admit  to  be  spent  in  their  reduction:  some  have  been  suc- 
cessfully replaced  at  the  end  of  eight  or  ten  days,  others  have 
proved  fatal  in  one.  This  difference  may  proceed  from  difference 
of  constitution  and  habit,  or  from  some  particular  circumstance  in 
the  disease  itself;  but  let  the  cause  of  it  be  what  it  may,  as  it  never 
can  be  absolutely  foreseen,  it  should  never  be  trusted;  the  sooner 
a  rupture  is  reduced,  the  sooner  the  patient  is  out  of  danger  from 
the  stricture,  and  the  sooner  will  he  be  rid  of  those  symptoms, 
which  it  has  already  occasioned. 

Recent  hernias  are  in  general  more  liable  to  stricture  than  old 

•  I  cannot  help  tliinking  that  the  present  machine,  which  is  used  for  the 
tobacco  clyster,  might  be  considerably  improved,  that  is,  might  be  made  to 
throw  in  the  fume  in  much  greater  quantity,  and  with  more  cert;iinfy.  A 
pump  is  now  made  for  this  purpose,  which  1  have  used  very  successfully. 


A  TREATISE  ON  RUPTURES.  339 

ones;  for  reasons  which  are  obvious  from  what  has  already  been 
said:  but  when  old  ones  get  into  the  same  circumstances,  the 
symptoms  are  much  the  same;  though  1  think  in  general  they  are 
not  altogeiher  so  pressing,  and  the  latter  generally  admit  of  more 
time  to  attempt  reduction  in.  The  smaller  the  portion  of  intestine 
which  is  engaged,  the  greater  the  pain  is,  and  the  more  hastily 
do  the  symptoms  advance.  I  have  seen  a  bubonocele  in  a  young 
woman  prove  fatal  in  less  than  a  day,  which  had  never  been  down 
before,  and  in  which  the  portion  of  intestine  was  so  small,  as 
hardly  to  engage  its  whole  canal. 

Omental  ruptures  in  general  are  not  subject  to  bad  symptoms 
arising  from  stricture;  though  they  will  sometimes  be  painful  and 
troublesome,  from  the  connexion  of  the  caul  with  the  viscera,  as  I 
have  often  seen.  As  this  is  an  accident  which  they  are  all  liable 
to,  they  should  never  be  suffered  to  remain  down,  if  they  are 
reducible;  and  that  not  only  on  this  account,  but  also  because  they 
render  the  patient  always  liable  to  the  descent  of  a  piece  of  gut. 
In  general  they  are  more  easy  of  reduction  than  the  intestinal, 
and  being  not  painful  will  admit  of  more  free  handling,  as  well 
as  more  time  to  be  spent  in  the  attempt.? 

I  have  already  mentioned  the  reasons  why  an  omental  rupture 
is  sometimes  incapable  of  being  reduced,  viz.  adhesion  to  the  sides 
of  the  hernial  sac,  or  such  an  alteration  in  the  form  of  it,  as  makes 
it  impossible  for  it  to  passs  through  the  abdominal  aperture. 
When  this  is  truly  the  case,  as  is  most  reasonable  to  suppose 
when  it  resists  all  proper  attempts,  there  is  no  remedy  but  to  sus- 
pend the  weight  of  it  in  a  bag-iruss,  and  thereby  render  it  as  little 
troublesome  as  possible.  This  is  indeed  all  that  can  be  done 
when  the  rupture  is  absolutely  irreducible;  but  in  books  will  be 
found  directions  to  leave  an  old  omental  hernia  down,  and  sus- 
pend it  in  a  bag,  even  though  it  should  be  reducible,  rather  than 
return  it  into  the  belly,  lest  it  should  lie  there  in  a  lump,  and 
make  the  patient  uneasy.  This  is  one  of  those  maxims  which 
writers  receive  from  each  other,  and  deliver  down  to  posterity, 

p  WiUers  of  good  credit  have  given  accounts  of  the  worst  symptoms  from 
a  mere  epiplocele;  in  Dionis may  be  seen  a  case  of  this  kind,  in  Gai'engeot, 
and  others. 


340  A  TREATrSE  ON  RUPTURES. 

without  inquiring  into  their  propriety.  It  may  in  some  few  par- 
ticular cases  be  right  to  do  so,  but  cannot  be  admitted  as  a  general 
rule:  surely  it  must  always  be  worth  while  to  try  how  it  will  be 
when  it  is  up,  rather  than  be  content  with  a  method,  which  is 
hardly  palliative,  and  which  always  may  be  productive  of  new 
evil. 

When  the  parts  are  fairly  reduced,  the  next  consideration  is, 
how  to  keep  them  from  falling  down  again:  this  can  only  be  done 
by  a  bandage,  the  pad  of  which  must  make  a  constant  pressure 
against  the  opening  in  the  abdominal  tendon,  and  thereby  not 
only  keep  the  gut  or  caul  from  pushing  out,  but  make  the  sides 
of  the  hernial  sac  approach  each  other  as  near  as  possible. 

In  the  making  and  adjusting  this  kind  of  bandage,  some  in- 
genuity is  necessary:  if  it  be  not  so  made,  and  so  put  on,  as  to  do 
good,  it  will  do  harm:  if  it  does  not  keep  the  intestine  up,  the 
patient  is  much  more  liable  to  mischief  with  it  than  without  it; 
and  it  has  often,  by  pressing  on  the  rupture  while  down,  proved 
very  pernicious,  in  cases  where  there  has  been  no  degree  of  stric- 
ture from  the  tendon.  It  therefore  behoves  every  surgeon  to  see 
that  the  truss  which  he  orders  is  well  made  and  properly  applied, 
lest  all  his  pains  should  be  baffled  by  the  bad  make,  or  injudicious 
application  of  this  piece  of  machinery. 

If  the  symptoms  of  pain,  inflammation,  &c.  ran  high  before  the 
parts  were  reduced,  they  will  not  always  cease  immediately  after; 
and  as  the  symptoms  which  remain  after  the  gut  is  returned,  dq 
in  all  probability  proceed  from  its  having  been  inflamed  by  the 
stricture,  such  remedies  as  are  proper  in  that  case  ought  to  be 
made  use  of;  the  body  should  be  kept  open,  and  the  diet  and 
regimen  should  be  low  and  sparing,  while  the  least  degree  of  ten- 
sion or  pain  remain;  in  short,  till  all  complaint  is  absolutely  re- 
moved from  the  abdomen,  and  the  intestines  do  tlieir  office  freely, 
and  without  trouble. 


4  TREATISE  ON  RUPTURES. 


SECT.  V. 


341 


I  AM  now  come  to  the  fourth  division,  under  which  I  compre- 
hended all  those  ruptures,  which  are  in  such  a  state  as  to  be  irre- 
ducible by  the  mere  hand,  and  in  which  a  chirUrgical  operation  is 
necessary  Tor  the  preservation  of  the  life  of  the  patient. 

Impracticability  of  reduction  may  be  owing  to  many  causes, 
most  of  which  have  already  been  recited;  such  are,  alteration  of 
the  form  of  the  parls  contained  in  the  hernial  sac,  largeness  of 
their  quantity,  adhesions  either  to  the  sac,  or  to  each  other,  or 
both,  and  a  stricture  made  on  the  intestine,  by  the  borders  of  the 
aperture  in  the  abdominal  tendon:  these  are  each  of  them  causes 
why  ruptures  are  sometimes  incapable  of  being  returned  back 
into  the  belly,  and  will  require  our  consideration  in  their  proper 
places;  but  in  this  it  is  my  intention  to  speak  only  of  the  last,  it 
being  that  which  calls  most  immediately  for  relief,  which  most 
frequently  requires  the  surgeon's  knife. 

Whether  the  primary  and  original  cause  of  the  mischief  arising 
from  this  stricture,  be  in  the  contained,  or  in  the  containing  parts 
of  a  rupture,  I  will  not  now  stay  to  inquire;  nor  whether  the  stric- 
ture made  by  the  tendon  be  a  cause,  or  an  effect;  but  shall  con- 
sider the  intestine  as  so  engaged  in  it,  as  to  be  rendered  incapa- 
ble of  being  returned  into  the  cavity  of  the  belly,  (by  the  hand 
only,)  and  suffering  in  such  manner,  by  being  so  bound,  as  to 
produce  a  series  of  bad  symptoms,  and  at  last  (if  not  relieved) 
death. 

This  stricture,  which  according  to  its  different  degrees  renders 
the  reduction  of  an  intestinal  hernia  either  difficult  or  impossible, 
is  according  to  such  degrees  productive  of  what  are  called  the 
symptoms  of  a  strangulated  rupture,  and  which  are  more  or  less 
pressing,  as  they  more  or  less  interest  the  life  of  the  patient. 

The  earliest  of  these  symptoms  were  related  in  the  former  sec- 
tion, as  attendant  on  those  ruptures  which  were  reducible,  though 
with  difficulty,  viz.  tumor  in  the  groin  or  scrotum,  attended  with 
pain,  not  only  in  the  part,  but  all  over  the  belly,  and  creating  a 
fickness  and  inclination  to  vomit,  suppression  of  stools,  and  some 


A  TREATISE  ON  RUPTURES. 

degree  of  fever:  these  are  the  first  symptoms,  and  if  they  are  not 
appeased  by  the  return  of  the  intestine,  that  is,  if  the  attempts 
made  for  this  purpose  do  not  succeed,  they  are  soon  exasperated; 
the  sickness  becomes  more  troublesome,  the  vomiting  more  fre- 
quent, the  pain  more  intense,  the  tension  of  the  belly  greater,  the 
fever  higher,  and  a  general  restlessness  comes  on,  which  is  very 
terrible  to  bear.  When  this  is  the  state  of  the  patient,  no  time  is 
to  be  lost:  a  very  little  delay  is  now  of  the  utmost  consequence; 
and  if  the  single  remedy  which  the  disease  is  now  capable  of  be 
not  administered  immediately,  it  will  generally  baffle  every  other 
atlempt.  This  remedy  is  the  operation,  whereby  the  parts  engag- 
ed in  the  stricture  may  be  set  free.  If  this  be  not  now  performed, 
the  vomiting  is  soon  exchanged  for  a  convulsive  hiccough,  and  a 
frequent  gulping  up  of  bilious  matter;  the  tension  of  the  belly,  the 
restlessness,  and  fever,  having  been  considerably  increased  for  a 
few  hours,  the  patient  suddenly  becomes  perfectly  easy,  the  belly 
subsides,  the  pulse  from  having  been  hard,  full,  and  frequent,  be- 
comes low,  languid,  and  generally  interrupted;  and  the  skin,  espe- 
cially that  of  the  limbs,  cold  and  moist;  the  eyes  have  now  a 
languor  and  a  glassiness,  and  a  lack-lustre  not  easy  to  be  de- 
scribed; the  tumor  of  the  part  disappears  and  the  skin  covering  it 
sometimes  changes  its  natural  colour  for  a  livid  hue;  but  whether 
it  keeps  or  loses  its  colour,  it  has  an  emphysematous  feel,  a  cre- 
pitus to  the  touch,  which  will  easily  be  conceived  by  all  who 
have  attended  to  it,  but  an  idea  of  it  is  not  so  easy  to  be  conveyed 
by  words:  this  crepitus  is  the  too  sure  indicator  of  gangrenous  mis- 
chief within.  In  this  state,  the  gut  either  goes  up  spontaneously, 
or  is  returned  with  the  smallest  degree  of  pressure;  a  discharge  is 
made  by  stool,  and  the  patient  is  generally  much  pleased  at  the 
ease  he  finds:  but  this  pleasure  is  of  short  duration,  for  the  hic- 
cough and  the  cold  sweats  continuing  and  increasing,  with  the  ad- 
dition of  spasmodic  rigors  and  subsultus  tendinum,  the  tragedy 
soon  finishes. 

These  are  the  symptoms  of  an  incarcerated  hernia,  this  their 
general  progress,  and  their  too  frequent  event.  The  first  class  of 
them  imply  some  degree  of  hazard,  but  are  often  capable  of  being 
relieved  without  the  use  of  the  knife;  the  latter  frequently  require 


A  TREATISE  ON  RUPTURES.  343 

it,  and  very  often  prove  fatal  by  the  neglect,  or  too  late  applica- 
tion of  it. 

Perhaps  there  is  not  in  the  practice  of  surgery  a  point  which 
requires  more  judgment,  firmness,  or  delicacy,  than  to  determine 
the  precise  time,  beyond  which  this  operation  should  not  be  de- 
ferred, and  for  a  surgeon  to  conduct  himself  so  as  to  induce  a  pa- 
tient to  submit  to  it  early  enough  for  his  preservation.  The  lime 
in  which 'a  piece  of  gut  will  become  gangrenous  from  stricture,  or 
get  into  a  state  approaching  to  that  of  a  gangrene,  is  extremely 
uncertain,  and  depends  upon  circumstances  which  no  man  can 
foresee.  There  have  been  several  instances  of  ruptures,  attended 
by  pressing  symptoms  of  stricture,  which  have  been  safely  re- 
turned by  the  hand  oioly,  at  the  end  of  several  days;  or  the  opera- 
tion having  been  performed  at  the  same  distance  of  time,  the 
parts  have  been  found  sound  or  unhurt:  on  the  other  hand,  there 
are  many  instances  producible,  of  the  intestine  having  been  with 
great  difficulty  replaced,  or  of  its  returning,  sua  sponte^  from  being 
mortified,  or  (the  operation  having  been  submitted  lo)  of  its  hav- 
ing been  found  in  such  state  by  the  operator,  at  the  end  of  not 
many  hours. 

I  have  myself  seen  a  small  portion  of  the  intestine  become  per- 
fectly gangrenous,  in  one  day  and  night  from  its  first  expulsion. 

The  directions  which  are  given  to  us  by  writers,  are  not  to  be 
trusted  without  much  circumspection;  the  signs  or  marks  which 
they  in  general  regard  as  proofs  of  the  proper  time  for  operating, 
are  most  frequent  proofs  that  the  time  is  just  elapsed,  and  that, 
instead  of  waiting  for  the  arrival  of  such  symptoms,  we  should 
have  prevented  them.  On  the  other  hand,  to  propose  an  opera- 
lion  of  so  much  consequence,  before  it  shall  be  thought  absolutely 
necessary,  may  admit  of  such  misconstruction,  as  no  man  would 
wish  to  have  put  upon  his  conduct.  Indeed,  I  do  not  know  any 
situation,  in  which  a  judicious  and  prudent  man  can  be  placed,  in 
which  it  will  behove  him  to  be  more  wary  and  circumspect,  more 
delicate,  or  more  steady. 

The  two  principal  circumstances  which  have  most  contributed 
to  the  infreqnency  of  performing  this  operation,  are,  a  dread  of 
great  hazard  from  the  operation  itself,  considered  abstractedly, 
and  a  fear  of  bringing  a  disgrace  upon  it,  by  having  performed  it 


344  A  TREATISE  ON  RUPTURES. 

too  late,  ne  occidisse^  nisi  servasset,  videretur.'^  The  first  of  these 
is  vastly  greater  than  it  ought  to  be,  and  is  most  frequently  the 
cause  of  the  latter;  so  that  if  the  one  can  justly  be  lessened,  the 
other  will  not  be  so  likely  to  happen. 

That  the  operation  considered  simply  is  not  void  of  hazard; 
every  man  who  knows  any  thing  of  the  nature  of  wounds  in  mem- 
branous and  tendinous  parts,  must  acknowledge:  they  are  cer- 
tainly subject  to  fever  and  inflammation,  are  difficult  and  slow  of 
digestion,  and  in  some  particular  habits  are  apt  to  become  gan- 
grenous; but  that  they  are  necessarily,  or  even  most  frequently 
hazardous,  daily  and  manifold  experience  contradicts. 

One  evil  is  very  frequently  the  parent  of  others.  By  being 
afraid  of  incurring  that  degree  of  hazard  which  is  thought  to  at- 
tend the  operation  merely,  the  generality  of  people  neither  attend 
to,  nor  embrace  the  most  proper  time  for  the  safe  performance  of 
it;  or  that  in  which  its  danger  must  be  necessarily  least,  be- 
cause least  combined  with  that  which  may  arise  from  the  state  of 
the  parts  within;  a  state  even  at  first  not  absolutely  safe,  but 
which  all  delay  beyond  a  certain  time  must  hourly  increase  the 
hazard  of. 

If  I  might  presume  to  give  my  opinion  on  this  subject,  I  should 
say,  that  the  operation  ought  always  to  be  performed  as  soon  as  pos- 
sible after  it  appears  that  all  rational  attempts,  by  large  and  free 
bleeding,  the  warm  bath,  clysters,  &c.  are  found  to  be  ineffectual, 
or  that  the  symptoms  rather  increase  than  decrease,  while  such 
means  are  made  use  of,   and  that  the"  handling  necessary  for 

9  Celsus. 

I  Perhaps  I  maybe  thought  somewhat  singulai' ;  but  from  what  I  havf 
seen,  I  am  much  inclined  to  believe,  that  when  the  parts  are  very  painful  to 
the  touch,  and  the  scrotum  large,  and  much  upon  the  stress,  more  harm  is 
generally  done  by  the  manual  attempts  for  reduction,  than  good.  In  this  state, 
the  great  distention  of  the  intestine  renders  it  very  incompressible,  and  very 
little  likely  to  be  returned  tlirough  the  tendinous  aperture  by  mere  force, 
(for  such  it  is,  in  whatever  degree  it  is  used,)  and  either  a  brisk  irritatin,^ 
purge,  or  a  very  stimulating  clyster,  (particularly  the  tobacco-smoke,)  are 
more  likely,  by  exciting  the  peristaltic  motion,  to  disentangle  it,  than  even 
the  most  judicious  method  of  handling  it.  And  in  cases  where  such  remedies 
have  been  previously  used,  I  verily  believe  the  sudden  reduction  of  the  piece 
of  gut  is  often  more  owing  to  their  effect  than  to  that  of  the  hand.    Uiit  I 


A  TREATISE  ON  RUPTURES.  345 

reduction  becomes  more  and  more  painful;  for  if  it  be  delayed  until 
the  inflammation  has  attained  a  certain  height,  though  the  parts 
upon  being  laid  open  are  not  found  quite  gangrenous,  that  is  no 
proof  that  the  want  of  success  must  be  set  to  the  account  of  the 
operation  merely.  That  state  of  inflammation,  either  of  the  in- 
testine or  of  the  hernial  sac,  which  is  just  not  gangrenous,  is  no 
state  of  safety,  nor  are  we  sure  that  removing  the  stricture  will  at 
this  time  appease  the  symptoms,  or  abate  the  hazard:  far  from  it: 
such  an  alteration  may  have  already  been  made  in  the  intestine, 
that  a  mortification  will  ensue,  though  it  be  set  free  and  returned 
into  the  belly.  A  ligature  need  not  be  continued  round  any  part 
of  a  living  animal,  until  it  becomes  quite  gangrenous,  in  order  to 
produce  its  destruction.  There  is  a  certain  point  of  time,  in 
which  the  circulation  is  so  prevented,  that  the  same  event  will 
follow,  though  the  ligature  be  then  removed.  It  is  indeed  a  nice 
and  no  very  easy  matter  to  find  this  precise  time:  but  this  diffi- 
culty and  uncertainty  are  the  strongest  reasons  for  anticipating 
rather  than  waiting  for  it;  for  when  in  the  present  case  such  time 
arrives,  or  is  nearly  arrived,  the  risk  of  the  operation  becomes 
complicated  with  that  arising  from  the  diseased  state  of  the  parts 
within;  and  the  chance  of  success  is  thereby  much  lessened. 

A  mortification  of  the  intestine  is  not  absolutely,  necessarily, 
and  always  fatal:  but  the  instances  of  those  patients  who  have 
escaped  with  life  in  these  circumstances  are  so  very  few,  that  it 
may  fairly  be  reckoned  among  the  deadly  diseases.  If  the  mor- 
tified gut  returns  back  into  the  belly,  upon  the  gangrene  taking 
possession  of  the  part  which  was  bound,  it  will  most  probably 
prove  fatal;  and  though  there  have  undoubtedly  been  instances 
of  people  who  have  survived  the  operation,  though  it  has  been  de- 
layed till  the  parts  have  been  in  such  condition,  yet  they  are  so 
very  rare,  that  they  are  hardly  sufficient  to  found  a  reasonable 
expectation  upon;  and  of  the  very  few  who  have  thus  escaped, 

must  desire  that  this  may  be  rightly  understood,  and  not  mistaken  for  a  dis- 
suasive against  manual  attempts  for  reduction ;  I  only  mean,  that  there  is 
such  a  state  of  an  incarcerated  intestine,  (which  state  I  have  just  described,) 
in  which,  from  its  size,  inflammation,  distention,  &c.  compression  by  the 
hand  is  very  little  likely  to  procure  its  return,  and  very  likely,  if  it  does  not 
do  so,  to  do  considerable  mischief, 

VOL.  I.  ,  X  X 


346  A  TREATISE  ON  RUPTURES. 

the  majority  have  been  obliged  to  hold  life  upon  terms  which 
have  oeen  very  fatiguing  and  disagreeable. 

When  the  operation  shall  be  thought  necessary,  the  manner  of 
performing  it  is  as  follows: — 

The  pubes  and  groin  having  been  clean  shaved,  the  patient 
must  be  laid  on  his  back,  on  a  table  of  convenient  height,  with 
his  legs  hanging  easily  over  the  end  of  it:  then  wiJh  a  straight  dis- 
secting knife  an  incision  must  be  made  through  the  skin  and 
membrana  adiposa,  beginning  just  above  the  place  where  the  in- 
testine passes  out  from  the  belly,  and  continuing  it  quite  down  to 
the  lower  part  of  the  scrotum.  Upon  dividing  the  adipose  mem- 
brane, there  generally  appear  a  few  small,  distinct,  tendinous  kind 
~of  bands,  which  lie  close  upon  the  hernial  sac,  which  must  be  di- 
vided also,  as  well  as  the  sac:  the  same  knife  with  which  the  in- 
cision through  the  skin  was  made  will  execute  this,  which  should 
be  done  wi(h  a  steady  hand  and  great  caution,  it  being  of  very 
different  degrees  of  thickness  in  diiferent  cases:  in  the  bubono- 
cele, or  that  which  is  confined  to  the  groin,  the  sac  is  most  fre- 
quently thin,  consequently  more  easily  divided,  and  requires 
greater  attention  in  the  operator:  in  the  oscheocele,  or  scrotal 
hernia,  if  it  be  recent,  the  sac  is  usually  thin  also;  if  ancient,  it  is 
sometimes  of  considerable  thickness;  but  whatever  be  the  state  of 
it,  if  the  o{)eralor  has  any  doubt,  let  him,  as  soon  as  he  had  made 
a  small  puncture  in  what  appears  to  him  to  be  the  hernial  sac,  en- 
deavour to  introduce  a  probe  into  it:  this  will  give  him  the  neces- 
sary satisfaction;  for  if  he  has  not  pierced  the  sac,  the  probe  will 
be  stopped  by  the  cells  of  the  common  membrane;  and,  if  he  has, 
it  will  pass  in  without  any  obstruction.  The  place  to  make  the 
incision  in  the  hernial  sac  is  about  an  inch  and  a  half  below  the 
stricture,  a::d  'he  opvning  need  not  be  larger  than  just  to  admit 
the  <  n  of  \be  operator's  forefinger,  which,  considering  the  grtat 
diiot  b^iiy  of  ihtse  membranes,  will  be  a  very  small  one.  The 
fore-finger  introduced  inio  this  aperture  is  the  best  of  all  directors, 
and  upon  that  a  narrow-biaded,  curved  knife,  wiih  a  bold  probe 
poiai,  will  be  the  only  instrument  necessary  to  finish  ihe  opera- 
tion. Wif.li  this  knife  on  the  finger,  (the  point  of  the  foim  r  be- 
ing alwajs  shori  of  the  exiremiiy  of  the  latter,)  the  sac  must  be 


A  TREATISE  ON  RUPTURES.  347 

divided  quite  up  to  the  opening  in  tiie  tendon,  and  down  to  the 
hotloui  of  the  scrotum. 

Upon  the  first  division  of  the  sac,  a  fluid  generally  rushes  out, 
which  fluid  is  dilTert^nt  in  quantity,  colour,  and  consistence,  ac- 
cording to  the  date,  size,  and  some  other  circumstances  attending 
the  rupture. 

This  fluid  has  sometimes  been  mentioned  as  a  defence  against 
an  accideat  from  the  knife,  in  the  first  division  of  the  hernial  sac, 
as  if  it  kept  the  intesane  at  such  a  distance,  as  diereby  to  lessen 
the  hazard  of  iSs  being  wounded;  but  this  is  a  very  fallacious  cir- 
cumstance, and  never  to  be  trusted:  the  security  of  this  operation 
depends  entirely  on  a  competent  kno.wledge  of  the  parts,  a  steady 
hand,  and  an  attentive  eye. 

Different  operators,  especially  among  the  French,  have  proposed 
a  number  of  different  instruments  for  the  safe  performance  of  this 
incision;  the  bistouri  cachee,  the  bistouri  herniare^  the  wii|ged  di- 
rector, the  blunt  scissors,  &c.  &c.  &c.  all  which  are  calculated 
for  the  defence  and  preservation  of  the  intestine,  in  the  division 
of  the  sac  and  tendon;  but  whoever  will  make  use  of  the  two 
knives  just  mentioned  will  find  that  he  will  never  stand  in  need 
of  any  other  instrument,  and  that  he 'will  with  them  be  able  to 
perform  the  operation  with  more  ease  to  himself,  with  less  hazard 
to  his  patient,  and  with  more'  apparent  dexterity,  than  with  any 
other  whatever. 

*  They  who  are  not  accustomed  to  perform  operations  of  such  conse- 
quence as  this  is,  are  apt,  from  timidity,  to  be  too  spuriug  in  making  their 
external  incision,  by  whicii  means  they  add  considerably  to  their  own  em- 
barrassment, and  to  the  futigue  of  the  patient.  A  free  division  of  ihe  hernial 
sac  and  scrotum,  downwards,  gives  room  for  the  more  easy  admission  of  tlie 
finger  into  the  stricture,  in  order  to  divide  it,  and  affords  an  opportunity  of 
handhng  the  intestine  or  omentum  more  gently,  as  well  as  more  properly, 
in  order  to  return  them  into  the  belly,  both  which  necessary  parts  of  the 
operation  are  much  impeded  by  a  small  incision. 

As  therefore  no  possible  advantage  can  arise  from  a  small  wound,  but  on 
the  contrary  it  may  be  attended  with  great  inconvenience  both  to  the  patient 
and  surgeon,  I  would  take  the  liberty  of  advising,  when  such  an  opening  is 
made  in  the  hernial  sac  as  will  admit  the  operator's  fore-finger,  and  upon  it 
his  knife,  that  he  immediately  divitle  the  sac  and  scrotum  down  to  the  bot- 
tom. It  is  true,  that  upon  such  division  the  quantity  of  intestine  will  seem  to 
be  increased,  and  an  ignorant  by-stander  may  be  alarmed  at  this  fallacious 


348  A  TREATISE  ON  RUPTURES. 

The  sac  being  laid  open,  the  intestine  generally  pushes  out  Im- 
mediately, (unless  it  is  confined,  by  being  enveloped  in  the  omen- 
tum,) and  appears  to  be  much  more  in  quantity  than  it  seemed  to 
be,  while  it  was  confined  within  the  scrotum. 

This  is  the  time  to  try  whether,  by  gently  drawing  out  a  little 
more  of  the  gut,  its  bulk  cannot  be  so  reduced  as  to  enable  the 
surgeon  to  return  it  back  into  the  belly,  without  dividing  the  ten- 
don. In  the  case  of  the  protrusion  of  a  very  small  piece  of  intes- 
tine it  has  been  found  practicable,  the  difficulty  of  returning  a 
large  portion  arising  principally  from  the  quantity  of  mesentery 
engaged  in  the  stricture;  and,  indeed,  though  it  may  now  and 
then  happen  that  a  small  piece  of  gut  may  be  returnable  without 
a  division  of  the  tendon,  yet,  if  it  cannot  be  very  easily  accom- 
plished, it  had  better  not  be  attempted,  since  in  the  state  in  which 
this  part  must  necessarily  be  to  require  the  operation  thus  far, 
any  degree  of  force  used  to  it  will,  most  probably,  be  more  pre- 
judicial and  hazardous  than  the  rest  of  it,  if  performed  properly 
with  a  knife. 

An  attention  to  the  natural  structure,  figure,  and  direction  of  the 
parts,  will  give  us  the  best  information  how  to  make  the  divisiou 
of  the  stricture  to  the  best  purpose,  and  with  the  least  hazard. 

The  tendon  of  the  obliquus  descendens  muscle  runs  in  aa 
oblique  direction  from  above  downward,  and  the  natural  opening 
which  is  always  found  in  it,  and  through  which  the  hernia  passes, 
is  made  by  a  kind  of  separation  of  the  fibres  from  each  oriier. 
The  direction  of  this  opening  is  the  same  as  that  of  the  undon, 
that  is,  obliquely  downward,  from  the  os  ilion  to  the  os  pubis:  the 
knife  therefore  should  be  so  managed,  as  rather  to  continue  this 
separation,  than  to  make  any  transverse  section;  its  edge  should  be 
applied  to  the  superior  and  posterior  part  of  the  oval,  and  carried 
upward,  and  obliquely  backward,  until  a  sufficient  opening  is 
made  to  serve  the  purpose.  By  this  means  the  fibres  of  the  ten- 
appearance,  which  is  produced  merely  by  the  confined  compressed  gut  be- 
ing set  free,  and  not  by  the  addition  of  any  more.  The  advantage  wliich  will 
arise  to  the  operator,  and  consequently  to  the  patient,  from  such  division  is 
real  and  great :  it  will  enable  tlie  former  to  finish  his  work  with  freedom,  aniA 
spare  the  latter  a  great  deal  of  pain 


A  TREATISE  ON  RUPTURES.  349 

don  will  be  rather  separated  from  each  other  than  cut,  and  in  all 
probability  the  risk  arising  from  the  incision  will  be  lessened. 

It  is  generally  advised  lo  make  the  division  of  the  stricture  free 
and  large,  as  well  to  permit  the  easy  return  of  ibe  parts,  as  to  pre- 
vent the  inconvenience  which  it  is  supposed  will  be  more  likely  to 
attend  a  small  wound  in  a  tendinous  body  than  a  large  one:  the 
first  intention,  the  easy  return  of  the  intestine,  should  certainly  be 
fulfilled,  and  therefore  the  incision  ought  always  to  be  large  enough 
for  that  purpose,  and  to  afford  an  opportunity  of  passing  the  end  of 
the  finger  round  on  the  inside  in  case  of  any  adhesion;  but  as  too 
large  an  opening  may  be  attended  with  very  ill  consequence,  it 
ought  also  to  be  guarded  against.  In  the  majority  of  cases,  a  small 
incision  will  be  found  sufficient  for  the  purpose  of  reduction;  and 
where  the  parts  are  free  from  adhesion,  and  the  safe  return  of 
them  is  the  only  object  of  attention,  a  small  division  made  in  the 
manner  already  directed  is  not  liable  to  any  more  pain  and  trouble 
than  a  large  one,  and  may  therefore  be  safely  trusted. 

Among  the  authors  who  write  from  each  other  and  not  from 
practice,  are  to  be  found  accounts  of  cases,  in  which  the  tendon 
only  has  been  divided,  and  not  the  hernial  sac,  which  latter  has 
been  returned  through  the  enlarged  opening,  with  its  contents 
enclosed;  and  the  same  writers  are  very  particular  in  their  direc- 
tions how  to  accomplish  this  operation.  If  it  was  practicable, 
(which  the  universal  adhesion  of  the  sac  with  the  cellular  mem- 
brane of  the  spermatic  chord  renders  absolutely  not  so,)  there 
would  be  still  several  material  objections  to  the  doing  it;  which 
objections,  as  the  thing  is  not  capable  of  being  executed,  it  is 
needless  to  mention. 


Though  I  am  perfectly  satisfied  that  the  case  of  a  strangulated 
hernia  is  most  frequently  as  I  have  represented  it,  viz.  that  the 
disorder  in  the  intestine  is  originally  produced  by  the  stricture 
made  on  it  by  the  borders  of  the  tendinous  opening  of  the  abdo- 
minal muscle,  and  that  the  gut  is  in  general  perfectly  sound,  and 
free  from  disease,  before  it  becomes  engaged  in  such  stricture,  yet 
I  think  it  right  to  acquaint  the  uninformed  reader,  that  it  has  been 
and  still  is  the  opinion  of  some  very  ingenious  men,  that  the  dis- 
ease is  originally  in  the  gut,  and  that  the  stricture  is  an  accident 


350  A  TREATISE  ON  RUPTURES. 

arising  from  the  inflammation  and  distenlion  of  it;  or,  in  other 
words,  that  the  intestine  is  first  inflamed,  and,  by  means  of  the 
alteration  produced  by  such  inflammation,  becomes  too  large  for 
the  tendinous  aperture,  which  therefore  makes  a  siriciure  on  it, 
and  which,  ihey  think,  is  tlie  reason  why  the  chirurgicai  operation 
is  often  unsuccessful. 

For  my  own  part,  I  cannot  think  that  either  the  fact  or  the 
inference  is  in  general  true. 

An  inflammation  most  certainly  may,  and  frequently  does, 
attack  any  part  of  the  imestinal  canal;  and  consequently  shat  part 
of  it  which  happens  to  be  included  within  a  hernial  sac  may  acci- 
dentally be  so  aflecled.  When  this  is  the  case,  the  swelling  and 
distention  which  naturally  and  necessarily  attend  an  inflammation 
of  the  gut,  will  render  it  less  capable,  or  perhaps  quite  incapable, 
of  repassing  the  opening  in  the  abdominal  tendon,  which  tendon 
mav  therefore  make  such  stricture  on  the  part  so  diseased,  as 
greatly  to  heighten  the  first  symptoms,  and  bring  on  si  ill  worse; 
and  when  this  happens,  the  operation  will  also  be  less  likely  to  be 
successful,  it  being  calculated  for  the  relief  of  only  such  symptoms 
as  arise  from  a  piece  of  intestine  (in  other  respec.s  sound  and  free 
from  disease)  being  so  bound  by  the  said  tendon,  as  to  have  its 
peristaltic  motion,  and  the  circulation  of  the  blood  through  it,  im- 
peded or  stopped:  whereas,  the  other  complaint,  consisting  pri- 
marily and  originally  in  an  inflammation  of  the  gut  itself,  the 
mere  removal  of  it  from  stricture  is  not,  nor  can  be,  equal  to 
the  cure  of  the  disease.  That  the  case  is  a  possible  one  I  make 
no  doubt,  having  once  or  twice  seen  it  in  old  ruptures;  but  it  is  a 
very  rare  one,  and  by  no  means  to  be  admitted  either  as  a  proof 
that  the  mischief  done  to  the  intestine,  in  the  generality  of  strangu- 
lated ruptures,  does  not  most  frequently  proceed  from  the  stric- 
ture made  by  the  tendon,  or  a  dissuasive  from  performing  an 
operation,  whenever  it  would  otherwise  be  thought  necessary. 

It  is  not  however  a  mere  speculative  point;  it  is  really  a  mat- 
ter of  consequence,  and  ought  to  be  attended  to  by  all  those  who 
have  it  in  their  power  to  make  frequent  observations  on  such  sub- 
jects; for  on  the  truth  or  falsehood  of  this  doctrine  depend  a  few 
very  material  points  in  practice,  some  of  which  ought  so  to  in- 


A  TREATISE  ON  RUPTURES.  351 

fluence  a  surgeon's  conduct  as  to  make  it  considerably  different  in 
one  case  from  what  it  should  be  in  the  other. 

Very  bad  symptoms,  such  as  pain,  tension  of  the  belly,  sickness, 
vomiting,  hiccough,  fever,  and  suppression  of  stools,  are  often  pro- 
duced in  a  very  short  space  of  time  by  the  descent  of  a  piece  of 
gut,  upon  some  exertion  of  strength  in  persons  who  were  imme- 
diately before  such  accident  at  perfect  ease,  and  free  from  all 
complaints  relative  to  the  belly.  If  the  disease  be  not  discovered, 
or  if  our  attempts  to  reduce  the  intestine  are  not  successful,  these 
symptoms  are  heightened,  and  the  patient  often  dies  of  a  mortifi- 
cation: if  we  do  succeed  in  the  timely  reduction,  all  these  terrible 
symptoms  often  cease  instantaneously,  and  the  patient  feels  neither 
pain  nor  inconvenience  of  any  kind  from  that  moment.  Would 
this  most  probably  and  most  frequently  happen,  if  the  disease  was 
generally  in  the  intestine,  and  the  stricture  of  the  tendon  merely 
accidental? 

In  that  kind  of  disease  of  the  intestinal  tube,  which  is  said  to 
be  produced  by  inflammation,  and  thought  to  be  attended  with 
spasmodic  stricture,  or  contraction  of  its  muscular  fibres,  there  is 
such  an  alteration  made  in  its  peristaltic  molion,  and  such  impe- 
diment in  the  execution  of  its  principal  offices,  that  what  is  taken 
into  the  stomach  is  rejected  by  vomit,  and  faeces  are  not  protruded 
through  the  colon  and  rectuni,  the  belly  is  tight  and  painful,  the 
skin  hot,  the  pulse  quick  and  hard,  and  the  patient  feels  a  rest- 
lessness and  anxiety  which  are  very  disagreeable:  this  is  one  of 
those  cases  which  require  immediate  assistance,  and  will  admit  of 
no  delay:  the  progress  of  the  symptoms  from  bad  to  worse  is  gene- 
rally very  rapid:  and  if  the  disease  be  not  soon  subdued,  the 
patient  dies.  Free  and  repeated  evacuation  by  phlebotomy  and 
lenient  purges,  the  use  of  a  semicupium,  a  warm  bath,  clysters, 
and  sometimes  brisk  cathartics,  joined  with  opium,  are  the  reme- 
dies generally  prescribed,  and  if  made  use  of  in  time  are  often  suc- 
cessful; but  if  n€glec!ed,  the  case  most  frequently  ends  ill. 

It  is  very  true  that  the  same  sympJoms  occur  in  a  strangulated 
hernia;  but  if  ihat  hernia  be  reducible,  they  generally  cease  upon 
such  reduction,  nor  <ioes  the  pa; lent  want  any  other  assistance 
than  what  is  necessary  to  prevent  a  new  descent  of  the  gut.  In 
this  respect  therefore  the  two  diseases  differ  very  materially:  in  the 


852  A  TREATISE  ON  RUPTURES. 

latter,  nature  stands  in  need  of  no  further  assistance  from  art,  but 
as  soon  as  the  ni.innal  operation  is  performed,  returns  to  the  execu- 
tion of  her  natural  functions;  in  the  former,  she  is  found  so  very 
insufficient  toward  assisting  herself,  that  it  seems  to  be  one  of  the 
few  cases,  in  which  medical  assistance  can  hardly  ever  be  dis- 
pensed with. 

Noiv,  if  (he  bad  symptoms  attending  an  irreduced  rupture  were 
primarily  owing  io  an  inflammation  of  the  intestine  within  it,  and 
that  the  tendinous  aperture  made  a  stricture  on  it,  only  in  conse- 
quence of  ihe  distention  of  the  gut — allowing  this  stricture  to 
aggravate  the  complaint  considerably — yet  the  division  of  it,  or 
the  reduction  of  the  intestine,  can  never  be  supposed  to  do  more 
than  alleviate  or  remove  such  aggravation;  the  original  inflamma- 
tion of  the  gut  tuust  stil!  remain,  nor  can  it  be  lessened  by  the  in- 
testine having  been  girt  tight  by  the  tendon;  and  yet,  as  I  have 
just  now  observed,  we  very  rarely  (at  least  in  ruptures  that  are  not 
of  ancient  date)  meet  with  any  trouble  or  complaint  after  reduc- 
tion 'is  timely  and  completely  made,  and  the  intestine  returned 
into  the  belly  in  a  sound  state;  the  vomiting  most  frequently  ceases 
immediately,  or  in  a  very  short  space  of  time;  a  discharge  is  made 
by  stool,  the  tension  of  the  belly  goes  off,  and  though  the  patient 
is  not  always  instantaneously  well,  in  cases  where  the  symptoms 
have  been  very  threatening,  yet  all  such  complaints,  as  proceeded 
from  an  obstruction  to  the  execution  of  the  proper  oflices  of  the 
intestinal  canal,  generally  disappear  immediately. 

From  the  nature  and  progress  of  the  symptoms  in  a  miserere, 
(as  it  is  called,)  from  the  extreme  pain  of  the  first  attack,  from  the 
perfect  ease  a  little  while  before  death,  and  from  the  mortified 
appearance  of  the  intestines  after  such  event,  I  think  it  is  most 
probable,  that,  if  we  could  have  an  opportunity  of  seeing  the  in- 
testine during  the  first  part  of  this  complaint,  we  should  find  all 
the  appearances  of  inflammation:  whereas,  in  many  of  those  upon 
whom  the  operation  for  the  bubonocele  is  successfully  and  timely 
performed,  this  is  not  the  case;  the  intestine  seldom  bears  marks 
of  high  inflammation,  unless  the  operation  has  been  long  delayed, 
nor  do  the  symptoms  of  such  complaint  usually  attend  afterward; 
the  mortified  part  often  does  not  exceed  an  inch,  or  an  inch  and  a 
half  in  length,  and  is  almost  always  confined  to  that  part  of  the  gut 


A  TREATISE  ON  RUPTURES,  353 

which  is  on  the  outside  of  the  tendinous  opening,  all  within  the 
belly  being  sound  and  fair.  To  which  may  be  added  this  circum- 
stance, that  when  the  parts  contained  in  a  hernial  sac  become 
mortified  by  the  delay  of  the  operation,  the  sac  itself,  (which  has 
no  immediate  connexion  with  the  intestine  or  its  vessels,)  the  cel- 
lular membrane  covering  it,  nay  the  skin,  is  often  found  in  the 
same  state. 

These  are  my  principal  reasons  for  believing  that  the  mere 
stricture  made  by  the  tendon  is,  in  the  generality  of  incarcerated 
ruptures,  not  only  a  sufficient,  but  the  primary,  and  indeed  the 
sole  cause  of  all  the  symptoms,  and  all  the  mischief;  and  there- 
fore I  must  also  be  of  opinion,  that  whoever  neglects  to  perform, 
or  at  least  to  propose  the  operation,  when  he  finds  reduction  iiTt~ 
practicable,  and  the  symptoms  pressing,  does  in  some  measure 
contribute  to  the  destruction  of  his  patient.' 

On  the  other  hand,  I  am  convinced,  by  some  instances  which  I 
have  met  with,  (and  which  one  time  or  other  I  hope  to  be  able  to 
present  to  the  public  in  a  collection  with  many  others,)  that  the 
©pinion  has  some  foundation  in  truth,  and  that  persons  labouring 
under  old  ruptures,  which  have  been  long  in  the  scrotum  without 
giving  any  trouble,  in  which  the  quantity  of  intestine  is  often  very 
large,  the  tendinous  aperture  much  dilated,  and  the  hernial  sac 
thick  and  firm,  are  those  to  whom  this  misfortune  has  happened, 
and  who  indeed,  if  their  case  be  duly  considered,  will  be  found 
most  liable  to  it;  there  being  no  reason  in  nature  why  that  part  of 
the  intestine  which  is  contained  in  such   a  hernia,  should  not  be 

«  Indeed,  though  we  should  Suppose  the  case  to  be  as  those  gentkmen 
have  represented  it,  viz.  that  the  complaint  begins  in  the  intestine,  and  that 
the  stricture  made  by  the  tendon  is  not  a  primary  cause,  but  an  effect  of  the 
disease,  I  do  not  see  how  we  can  avoid  proposing  the  opei-ation  ;  for  whether 
the  increased  size  of  the  gut  be  owing  to  the  inflammation,  which  renders  it 
too  large  to  pass  the  abdominal  opening,  or  whether  it  be  the  mere  effect  of 
stricture  made  by  the  tendon,  in  either  case  it  will  bind  equally,  and  the 
event  must  be  exactly  the  same,  as  far  at  least  as  the  stricture  has  to  do 
with  it :  for  when  the  intestine  is  inflamed,  whether  such  inflammation  pre- 
ceded or  succeeded  the  confinement  of  it  by  the  tendinous  opening,  the 
symptoms  can  never  be  appeased,  but  by  the  release  "of  tlie  gut  from  itr 
confinement. 

VOL.^  I.  -         TV 


354  A  TRKATlSli  0I'«  RUPTURES. 

subject  lo  every  complaint,  or  disease,  to  which  every  other  part 
of  that  canal  is  liable;  and  this  opinion  I  am  more  confirmed  in,  by 
having  met  vvifii  more  tlian  one  subject  with  such  old  ruptures., 
who  have  had  all  the  symptoms  of  a  strangulation;  and  in  v^'hom, 
I  am  sure,  there  was  no  stricture  made  by  the  tendon,  though  the 
gut  remained  in  the  scrotum. 

Although  I  have  through  the  course  of  this  section  repeatedly 
recommended  the  early  performance  of  the  operation,  yet  I  must 
desire  not  to  be  niisundefslood,  as  if  I  meant  to  advise  it  before 
proper  attempts  iiad  been  made  for  reduction,  or  the  symptoms 
become  alarming;  much  less  that  I  would  propose  it  as  a  means 
to  obtain  a  radical  cure  in  those  ruptures  which  are  returnable  by 
the  hand  merely;  a  thing  boasted  of,  and  practised  by  pretenders, 
but  not  to  be  thought  of  by  any  man  who  has  either  judgment, 
humanity,  or  honesty. 

The  only  intent  of  it  should  be  to  preserve  life,  by  rescuing  the 
patient  from  the  hazard  of  mortification,  likely  to  ensue  from  the 
stricture;  and  though  I  have  pressed  it  with  such  view,  and  in  such 
circumstances,  and  think  it  ought  always  to  be  done,  yet  I  should 
be  rery  sorry  to  have  it  thought  that  I  encouraged  the  performance 
of  it  wantonly,  or  unnecessarily,  which  must  be  the  case,  when- 
ever it  is  done  with  any  other  intention. 

Considered  as  a  means  to  obtain  a  perfect  or  radical  cure,  or  to 
prevent  the  necessity  of  wearing  a  truss,  every  man  at  all  conver- 
sant with  these  things  knows,  that  it  most  frequently  fails  of  pro- 
curing that  end;  and  that  most  of  those  people  who  have  been 
obliged  to  submit  to  it  for  the  preservation  of  their  lives,  have  also 
been  obliged  to  wear  a  bandage  ever  afterwards,  to  prevent  the 
intestine  from  slipping  down  behind  the  cicatrix  into  the  groin. 

In  short,  though  the  danger  from  the  operation,  when  perform- 
ed in  time,  is  in  my  opinion  never  to  be  mentioned  with  that  which 
must  arise  from  the  stricture,  if  neglected,  yet  such  operation 
never  ought  to  be  attempted  but  with  a  view  to  prevent  the  im- 
pending ill  effects  of  such  stricture,  and  will  not  ever  (I  dare  be- 
lieve) be  put  in  practice  with  any  other  intention,  by  any  fair  or 
judicious  practitioner,  by  any  man  who  has  the  least  regard  for 


A  TREATISE   ON  RUPTURES.  35£i 

his  own  character,  bis  feilovv-creaturc's  sensations,  or  for  any  thing 
but  money." 

The  sac  and  stricture  being  laid  open  and  divided,  the  contained 
parts  come  into  view,  and,  according  to  the  different  circum- 
stances of  the  rupture  and  of  the  patient,  will  be  found  in  differ 
ent  states,  and  require  different  treatment. 

These  states  are  reducible  to  three  general  heads,  that  is,  the 
contained  parts  will  be  found,  either  in  a  sound,  healthy,  loose, 
unconnected  state,  and  fit  for  immediate  reduction;  or  in  a  sound 
state,  but,  from  some  particular  circumstances,  incapable  of  being 
immediately  replaced;  or  in  an  unsound  diseased  state,  and  re- 
quiring to  be  treated  accordingly. 

If  the  rupture  consists  of  a  piece  of  intestine  only,  and  that 
oeither  mortified  nor  adherent,  the  sooner  it  is  returned  the  better, 
and  the  more  gently  it  is  handled  for  reduction  the  better  also. 

If  the  intestine  be  accompanied  with  a  portion  of  omentum,  the 
latter  (if  in  a  proper  state)  should  be  returned  first. 

In  returning  the  intestine,  care  should  be  taken  to  endeavour  to 
put  in  that  part  first  which  came  out  last,  otherwise  the  gut  will 
be  doubled  on  itself,  and  the  difficulty  and  trouble  be  thereby 
much  increased;  and  in  making  the  reduction,  the  fingers  should 
be  applied  to  that  part  of  the  intestine  which  is  connected  with 
the  mesentery,  rather  than  its  convex  part,  as  it  will  both  serve 
the  purpose  better,  and  be  less  likely  to  do  mischief. 

While  the  reduction  is  making,  the  leg  and  thigh  on  the  rup- 
tured side  should  be  kept  elevated,  as  such  position  of  the  limb 
will  much  facilitate  the  return  of  the  parts. 

Long  confinement  in  the  scrotum  will,  in  some  people,  produce 
slight  adhesions,  by  slender  filaments,  which  are  generally  very 
easily  separated  by  the  finger,  or  divided  by  a  knife,  or  scissors, 

'°  Perhaps  it  may  appear  extraordinary,  but  this  necessarily  severe  opera- 
tion has,  by  some  of  our  modern  quacks,  been  recommended,  and  even 
practised,  for  the  cure  of  omental  hernias :  more  tlvan  one  person  has  lost 
his  life,  that  is,  has  been  murdered  in  the  attempt  :  but  that  seems  to  be 
a  circumstance  of  small  importance  in  the  minds  of  these  operators,  nor 
does  it  at  all  prevent  the  credulous  part  of  mankind  from  trusting  them ; 
though  one  would  imagine  that  much  stronger  proofs,  either  of  the  judg 
ment,  humanity,  or  honesty  of  Puch  practitioners,  were  not  requisite. 


356  A   TRKATISE  ON  RUPTURES- 

wbether  the  adhesions  be  of  the  parts  of  the  intestine  inter  se,  or 
to  the  hernial  sac.  If  the  adhesion  be  of  the  former  kind,  anti 
such  as  proves  very  difficult  to  separate,  it  will  be  better  to  return 
the  gut  into  the  belly  as  it  is,  than  to  run  the  risk  of  producing  an 
inflammation  by  using  force:  if  it  be  of  the  latter,  that  is,  if  the 
connexion  be  with  the  sac,  there  can  be  no  hazard  in  wounding 
that,  and  therefore  it  may  be  made  free  with. 

It  has  been  said  by  some  writers,  that  if  the  piece  of  omentum 
be  so  very  adherent  that  the  surgeon  does  hot  choose  to  separate  it, 
that  it  may  very  safely  be  left,  that  it  will  first  suppurate,  and  then 
shrink,  and  very  little  retard  the  healing  of  the  sore.  What  expe- 
rience the  gentlemen  who  talk  in  this  manner  may  have  had  of  this 
kind  of  case,  I  know  not;  but  I  never  yet  have  seen  any,  in  which 
it  could  possibly  be  thought  necessary  to  leave  the  patient  in  such 
circumstances,  or  in  which  an  attachment  of  the  omentum  was  in- 
capable of  being  set  free,  either  by  dissecting  its  adhesions,  or  re- 
trenching a  part  of  it. 

The  prolapsed  part  being  replaced,  the  next  object  of  consider- 
ation is  the  hernial  sac:  this,  if  large,  thick,  and  hard,  will  prove 
slow  and  difficult  of  digestion,  render  the  edges  of  the  sore  tumid 
and  painful,  and  often  retard  a  cure  considerably,  by  producing 
troublesome  abscesses  in  the  scrotum. 

A  considerable  part  of  it  may  very  safely  and  properly  be  re- 
moved: no  part  of  it  is  of  any  consequence  except  the  posterior,  or 
that  with  which  the  spermatic  vessels  are  connected:  all  the  rest 
being  loose,  by  means  of  the  cellular  membrane,  is  therefore  very 
easily  separable,  and  had  therefore  better  be  removed  than  left." 

"  The  removal  of  part  of  the  sac  might  have  been  right  when  the  practice 
was  to  fill  the  cavity  witli  dressings,  which  induced  a  necessity  for  the  mem. 
branous  sac  to  slough,  but  was  very  contrary  to  Mr.  Pott's  pi-actice  in  the 
latter  part  of  his  life  ;  and,  if  he  had  lived  to  produce  a  new  edition  of  this 
treatise,  as  he  had  projected,  I  have  no  doubt  but  that  this  passage  would 
have  been  altered.  The  method  which  we  have  long  used,  and  which  Mr. 
Pott  himself  practised,  is  this :  when  the  contents  of  the  sac  are  returned 
into  the  abdomen,  the  sides  of  the  scrotum  are  brouglit  together,  by  which 
means  the  parts  of  the  divided  sac  are  also  brought  into  contact,  a  large  armed 
needle  is  then  passed  through  the  upper  part  of  the  scrotum  near  to  the  ab- 
dominal ring,  and  made  to  dip  down,  so  as  to  pass  through  the  sides  of  the 
sac,  but  by  no  means  so  deep  as  to  run  any  risk  of  including,  or  even  injur  - 


A  TREATISE  ON  RUPTURES-  357 

It  has  been  proposed  by  theoretic  writers  to  pass  n  ligature 
round  the  upper  part  of  llie  neck  of  the  sac,  in  order,  as  it  is  said, 
to  procure  the  union  of  its  sides,  and  thereby  more  certainly  to  pre- 
vent the  future  descent  of  any  thing  from  the  betly;  but  to  this 
there  are  many  objections:  the  principal  of  which  are,  (hat  if  the 
ligature  was  not  made  strict,  it  could  serve  no  purpose;  and  if  it 
was,  it  would  be  very  likely  to  injure  the  spermatic  chord,  if  in- 
cluded in  it.  By  preventing  part  of  the  discharge,  it  might  also 
occasion  very  troublesome  symptoms,  and,  upon  the  whole,  ia  by 
no  raeans  advisable. 

It  has  also  been  supposed,  that  the  intestin.e  may  be  found  so 
inherent  as  not  to  admit  of  being  set  free;  and  in  this  case,  it  has 
been  advised  to  remove  the  stricture,  by*  dividing  the  sac  and  the 
tendon,  and  then  to  leave  the  parts  loose.  This  is  mentioned  by 
many  writers  of  eminence,  and  therefore  I  have  taken  notice  of  it, 
though  it  is  a  kind  of  case  which,  I  must  own,  I  have  never  seen, 
nor  do  I  suppose  that  I  ever  shall.  I  have  seen  the  intestines  very 
firmly  adherent  to  each  other,  to  the  sac,  to  the  omentum,  and  tp 
the  testicle;  but,  never  in  such  a  state  of  adhesion,  as  to  be  inca- 
pable of  being  returned.  The  adhesion  of  the  parts  of  the  intes- 
tine inter  se  are  most  frequently  easily  separated;  but  if  they  should 
not,  still  these  are  no  hinderance  to  the  gut  being  returned;  and  if 
the  caul  be  so  connected  as  to  prove  troublesome  to  detach,  it  may 
with  great  safety  be  cut  off;  so  that  the  connexion  here  meant  must 
be  of  the  intestine  with  the  hernial  sac:  of  these  two  parts  we  are 
interested  only  for  the  preservation  of  one,  and  may  without  ha- 
zard make  free  with  the  other.  The  separation  may  indeed  be 
tedious,  and  sotiietimes  difficult;  but,  let  the  difficulty  or  trouble  1?€ 
what  they  may,  the  separation  must  be  accomplished,  it  being  ab- 

ing,  in  the  smallest  degree,  the  spermatic  vessels,  by  which  mode  the  objec- 
tion in  the  paragraph  which  follows  in  the  text,  is  done  away;  the  ligature 
is  then  to  be  tied  moderately  fast,  which  makes  a  powerful  barrier  against  the 
reprotrusion  of  the  intestine.  Two  or  three  stitches,  according  to  the  size 
of  the  incision,  are  then  to  be  made  through  the  sides  of  the  divided  scrotum-i 
there  is  no  necessity  for  these  to  pass  through  the  sac,  as  the  only  intention 
of  them  is  to  keep  the  parts  together,  so  as  to  prevent  the  exposure  of  the 
sac,  by  which  means  no  digestion  of  it  will  take  place,  but  the  parts  will 
coalesce,  and  generally  he%l  by  the  first  intention.     E. 


358  A  treatisl;  on  ruptures. 

surJ  to  think  ol'  h^Tviiig  a  piece  of  intestine  loose,  in  the  dividea 
scrotum,  which,  from  the  removal  of  the  stricture  above,  will  be 
liable  to  be  increased  in  quantity,  from  every  unguarded  motion, 
and  subject  to  all  the  inconveniences  which  the  influence  of  the 
air  must  necessarily  produce  on  such  tender  parts;  not  to  mention 
the  great  diflicuUy  of  managing  the  sore  in  this  state,  and  the  pain 
and  other  bad  symptoms  which  must  arise  from  the  daily  uncover- 
ing the  intestine.  Any  trouble,  therefore,  which  may  attend  the 
separation,  must  be  submitted  to,  rather  than  to  follow  this  strange 
advice,  which,  indeed,  the  writers  who  give,  seem  not  to  under- 
stand; for,  to  leave  the  parts  as  they  were  found,  and  as  they  di- 
rect, is  impossible:  they  were  found  contained  in  a  hernial  sac, 
and  in  the  scrotum,  defended  from  the  air,  and  in  some  degree  li- 
mited as  to  quantity,  both  by  the  stricture  above,  and  the  sac  be- 
low; the  necessary  operation  has  removed  that  stricture,  divided 
the  sac  and  scrotum,  and  set  all  loose  and  free;  and,  therefore,  if 
the  intestine  be  not  returned  into  the  belly,  and  kept  there,  the 
quantity  which  may  fall  out  may  be  so  large  as  to  produce  the 
most  fatal  consequences,  notwithstanding  any  attachments  which 
some  part  of  the  canal  may  have  contracted. 


SECT.  Vi. 


Hitherto  the  pat  Is  composing  a  rupture  have  been  considered 
*^s  displaced,  as  inflamed,  as  having  contracted  unnatural  connex- 
ions and  adhesions,  but  being  still  so  unhurt  in  their  texture  as  to 
remain  sound,  within  the  laws  of  the  circulation,  fit  to  be  return- 
f'A  into  the  belly,  and  affording  a  reasonable  prospect  of  success 
in  the  event. 

But,  on  the  other  hand,  if  the  inflammation  ran  very  high,  and 
lias  cither  been  neglected,  or  not  given  way  to  proper  treatment, 
and  the  operation  has  been  too  long  deferred,  the  parts,  though 
loose,  may  berorne  so  diseasedj  as  to  be  unfit  for  immediate  re- 
«^uetion. 


A  TREATISE  ON  RUPTURES.  359 

The  disease  here  meant  is  gangrene,  or  morlificalion,  produced 
by  the  stoppage  of  the  circulation  of  the  blood  through  the  part 
which  is  on  the  outside  of  the  stricture.  The  gangrenous  or  mor- 
tified state  of  these  parts  may  be  of  more  or  less  extent,  according 
to  the  quantity  contained  in  the  sac;  but  be  the  extent  of  such  dis- 
ease what  it  may,  the  part  so  aifected  ought  never  to  be  returned 
loose  into  the  belly,  (more  especially  if  it  be  intestine,)  withont 
some  caution. 

The  omentum  indeed  may  be  made  more  free  wlili.  If  this 
be  so  altered  as  to  be  plainly  unfit  for  immediate  reduction,  it  may 
be  removed;  that  is,  the  altered  part  may  be  cut  oif  from  the 
sound. 

This  is  certainly  true;  but  it  is  a  point  of  practice  which  ap- 
pears to  me  to  deserve  somewhat  more  regard  than  is  most  com- 
monly paid  to  it  by  writers.  All  that  is  generally  said  of  it  is, 
that  if  the  omentum  be  found  in  an  unsound  state,  a  ligature 
should  be  made  on  it  just  above  the  altered  part:  what  is  below 
such  ligature  should  be  cut  off,  and  the  ligature  should  be  left 
hanging  out  of  the  wound,  that  it  may  more  easily  be  taken  away, 
when  it  is  cast  off  This  is  the  general  doctrine,  and  indeed  the 
general  practice;  but  which  I  cannot  help  thinking  is  delivered 
down,  and  followed  by  us,  somewhat  inconsiderately. 

When  the  omentum  is  in  such  state  as  to  be  fit  for  being  re- 
turned into  the  belly,  such  return  ought  never  to  be  neglected  or 
omitted;  the  uses  of  the  caul  are  great  and  obvious,  and  the  want 
of  it  must  be  productive  of  inconvenience  to  the  patient;  its 
warmth,  its  greasiness,  its  lubricity,  its  extension  over  the  surface 
of  the  intestines,  together  with  the  constant  motion  of  that  canal, 
prove  its  utility,  and  in  some  measure  point  out  what  the  incon- 
veniences must  necessarily  be,  which  follow  the  removal  of  it. 
But  it  is  sometimes  found  in  such  state,  as  to  be  unfit  for  reduc- 
tion; and  then  we  must  embrace  the  lesser  of  the  two  evils,  and 
remove  such  part  of  it  as  we  ought  not  to  return.  This  is  said 
by  every  body,  and  is  certainly  true;  but  seems  to  me,  as  I  have 
just  now  observed,  to  require  more  consideration  than  is  generally 
spent  upon  it,  as  well  with  regard  to  the  state  requiring  such 
operation,  as  the  manner  of  executing  it.  It  is  commonly  said, 
ihat  if  it  be  found  in  large  quantity,  considerably  hrirfl(?ned.  or  if 


360  A  TREATISE  ON  RUPTURES. 

it  be  altered  in  its  texture,  (that  is,  by  gangrene  or  morlitication,) 
that  it  ought  to  be  retrenched.  The  two  states  said  to  require 
this  retrenchment  are  very  materially  different  from  each  other: 
the  necessity  of  it  in  the  latter  is  evident;  but  I  cannot  help  say- 
ing, that  I  think  it  is  ordered  in  the  former  very  unnecessarily; 
and  that  the  general  method  also  of  performing  it  in  the  latter 
appears  to  me  both  injudicious  and  prejudicial.  There  may  pos- 
sibl}'  now  and  then  occur  a  case,  in  which  such  alteration  may 
have  been  made  in  the  mere  form  and  consistence  of  the  pro- 
lapsed piece,  by  induration,  enlargement,  &,c.  that  the  removal  of 
a  part  of  it  may  become  necessary;  but  this,  though  it  does  happen 
sometimes,  is  very  unfit  to  be  made  a  general  rule  of.  The  reason 
given  is,  that  it  will  lie  uneasy  in  a  hard  lump  within  the  pa- 
tient's belly;  which  is  not  necessarily  or  generally  true,  as  I  have 
several  times  experienced;  having  returned  it  when  its  form  and 
consistence  have  been  much  altered,  without  finding  any  future 
inconvenience:  so  that  such  alteration  merely  is  not  a  general  rea- 
son for  cutting  it  off.  On  the  other  hand,  I  am  ready  to  allow, 
that  it  sometimes  is,  and  that  the  piece  of  caul  so  altered  had  bet- 
ter be  removed,  and  that  it  may  also  be  so  connected,  that  it  will 
be  more  to  the  patient's  advantage  to  have  such  connected  part 
taken  away  at  once,  than  to  go  through  the  pain  and  fatigue  which 
the  separation  may  require;  in  which  case,  my  objection  lies  prin- 
cipally against  the  prescribed  method  by  ligature.  Indeed,  when 
it  is  in  a  gangrenous  state,  a  part  of  it  must  necessarily  be  re- 
moved, as  such  state  makes  the  return  of  it  into  the  belly  highly 
improper.  To  accomplish  this,  we  are  ordered  to  make  a  liga- 
ture on  the  sound  part  of  the  omentum,  just  above  what  is  altered, 
and  then  to  cut  it  off  immediately  below  such  ligature:  and  the  rea- 
son given  for  doing  it  in  this  manner  is,  that  all  the  altered  part 
may  be  removed  without  any  risk  of  haemorrhage.  This  method 
of  acting  is  founded  on  a  groundless  fear,  and  is  often  attended 
with  bad  consequences,  which,  not  being  supposed  to  flow  from 
this  cause,  are  not  set  to  its  account. 

The  fear  of  haemorrhage  from  the  divided  vessels,  if  the  omen" 
tum  be  cut  in  a  sound  part,  and  the  apprehension  of  mischief 
likely  to  ensue  from  the  shedding  of  sanies  or  matter  into  the 
belly,  if  the  division  be  made  in  the  diseased,  gave  lise  to  the 


A  TREATISE  ON  RUPTURES.  361 

practice  of  tying  it  before  amputation;  but  neither  one  nor  the 
other  of  these  apprehensions  is  well-grounded,  nor  are  they 
sufficient  reasons  for  such  practice. 

The  fear  of  haemorrhage  is  almost  if  not  perfectly  without  foun- 
dation, as  I  have  several  times  experienced;  and  the  discharge  of 
a  fluid  of  whatever  kind  from  the  border  of  the  divided  membrane, 
is  of  no  consequence  at  all;  neither  would  the  ligature  prevent  it 
if  it  was,  as  must  appear  to  every  one  who  will  give  the  subject 
one  moment's  serious  consideration. 

But  this  is  not  all:  I  am  sorry  to  say  that  1  am  by  experience 
convinced,  that  making  a  ligature  on  the  caul  is  not  only  unne- 
cessary, but  frequently  pernicious,  and  sometimes  even  fatal. 

A  mere  theoretical  consideration  of  the  parts  will  convince  any 
one  of  the  probability  of  mischief  arising  from  such  practice;  but, 
besides  these  considerations,  I  can  take  upon  me  to  say,  that  I 
have  seen  it  add  to  the  hazard  of  the  case,  and  more  than  once 
destroy  the  patient.  I  have  seen  the  omentum  become  diseased, 
and  gangrenous  in  all  its  extent  above  the  ligature,  between  it  and 
the  stomach,  when  it  was  not  gangrenous  at  all  before  it  was  tied; 
but  on  the  contrary,  in  a  sound  state,  and  only  tied  in  order  to  its 
being  more  securely  retrenched.  I  have  seen  a  whole  train  of 
bad  symptoms,  such  as  nausea,  vomiting,  hiccough,  fever,  anxiety, 
restlessness,  great  pain  in  the  belly,  and  an  incapacity  of  sitting 
upright,  or  even  of  moving  without  exquisite  pain,  precede  the 
death  of  a  man,  whose  omentum  was  lied  merely  because  of  its 
enlargement,  whose  intestines  uninterruptedly,  from  the  time  of 
the  operation  to  his  last  hour,  performed  their  proper  office  of  dis- 
charging the  faeces,  and  were  found  perfect  and  untainted  after 
death,  but  whose  omentum  appeared  in  a  highly  inflammatory 
state  in  general,  and  in  many  parts  above  the  ligature  gangrenous. 

The  direction  given  by  many  writers  to  put  the  patient's  body 
in  motion,  or  to  give  him  a  kind  of  shake,  in  order  to  set  to  rights 
the  disturbance  and  derangement  produced  by  tying  the  caul, 
would  be  too  absurd  to  mention,  did  it  not  serve  to  prove,  that 
even  the  very  people  who  have  persisted  in  this  pernicious  prac- 
tice were  themselves  sensible  of  some  of  its  probable  ill  conse- 
quences, though  they  would  not  try  to  remedy  them:  they  thought, 
that  those  which  might  follow  from  hcemorrhage,  or  the  discharge 

VOL.    T.  7.    7. 


362  ■  A  TREATISE  OJS'  RUPTURES. 

of  sanies,  were  still  greater,  but  made  no  experiment,  in  order  to 
know  whether  they  were  or  not. 

~  I  will  not  pretend  to  say,  that  there  never  was  a  dangerous  or 
fatal  flux  of  blood,  from  the  division  of  the  omentum,  without 
ligature:  but  1  can  truly  say  that  I  never  saw  one;  that  I  have  se- 
veral times  cut  off  portions  of  it,  without  tying,  and  never  had 
trouble  from  it  of  any^  kind,  though  I  have  always  made  the..  eX" 
cision  in  the  sound  part;  and  that,  from  the  success  which  has  at- 
tended it,  I  shall  always  continue  to  do  so,  whenever  it  shall  be- 
come necessary.  Upon  the  whole,  I  cannot  help  thinking  the 
ligature  both  unnecessary  and  pernicious,  and  can  venture  from 
experience  to  say,  that  any  portion  of  the  caul,  which  it  may  be 
thought  necessary  to  remove,  may  very  safely  be  cut  off,  without 
any  previous  tying. 

The  best  and  safest  method  of  performing  this  operation,  is  ' 
with  a  good  pair  of  straight  scissors,  having  first  expanded  it,  as 
well  on  account  of  its  more  easy  division,  as  to  prevent  the  mis- 
chief which  would  attend  the  cutting  a  piece  of  intestine,  if  it  should 
chance  to  be  wrapped  up  in  it;  and  if  any  fear  slill  remains  of 
haemorrhage,  the  excision  may,  in  the  case  of  mortification,  be 
made  just  within  the  altered  part  of  it;  in  which  case,  there  will 
no  more  be  left  to  be  cast  off,  than  ther^  must  be  when  a  iigaiure 
is  made. 

If  the  gangrene,  or  sphacelus  has  taken  possession  of  the  in- 
testine, and  consists  of  a  small  spot  only,  which,  by  casting  off, 
might  endanger  the  shedding  its  contents  into  the  belly,  the  me- 
thod of  endeavouring  to  prevent  that  inconvenience  is  by  con- 
necting the  upper  part  to  the  wound  by  means  of  a  needle  and 
strong  ligature:  by  this  means,  when  the  mortified  part  separates, 
the  faeces  are  discharged  by  the  wound  for  some  time;  after  which 
it  has  been  known  to  contract  gradually,  and  heal  firmly:  but 
whether  the  event  prove  so  happy  or  not,  this  method  of  securing 
the  gut  should  never  be  omitted. 

In  making  this  artificial  attachment  of  the  intestine  to  the  in- 
side of  'he  belly,  care  must  be  taken  not  to  wound  the  gut;  the 
needle  must  be  passed  through  the  mesentery,  at  a  small  distance 
from  the  intestine,  and  such  a  portion  of  that  body  included  with- 
in the  stitch,  as  shall  be  likely  to  hold  fast  long  enough  to  render 


A  TREATISE  ON  RUPTURES.  363 

the  connexion  probable.  If  the  altered  portion  of  the  gut  be  of 
such  extent  as  to  require  excision,  but  yet  not  so  large  as  to  pre- 
vent the  extremities  of  the  divided  parts  from  being  brought  into 
contact  with  each  other,  their  union  must  be  endeavoured  by  su- 
ture. In  doing  this,  the  ends  of  the  intestine  should  be  made  to 
lay  somewhat  over  each  other,  by  which  means  the  suture  will  be 
the  stronger;  and  when  the  two  ends  are  thus  sewed  together, 
they  must  both  be  fastened  to  the  inside  of  the  belly,  at  the  upper 
part  of  the  wound,  that  in  case  the  union  does  not  take  place,  the 
discharge  of  faeces  may,  if  possible,  be  made  through  the  groin. 
But  if  the  disease  be  of  such  extent  as  to  prohibit  the  bringing 
the  two  ends  together,  the  treatment  must  be  different.  In  this 
case,  as  it  is  impossible  to  preserve  thecontinuity  of  the  intestinal 
canal,  the  aim  of  the  surgeon  must  be  to  prevent  the  contents  of 
it  from  being  shed  into  the  belly,  and  to  derive  through  the  wound 
in  the  groin  all  that  which  should,  in  a  sound  and  healthy  state, 
pass  off  by  the  rectum  and  anus. 

To  accomplish  this,  he  must  take  care  that  neither  extremity 
of  the  divided  intestine  slip  out  of  his  fingers;  then  with  a  proper 
needle,  and  a  strong  ligature,  he  must  connect  both  of  them  to  the 
upper  edge  of  the  wound.  The  suture,  wiih  which  the  connexion 
is  made,  must  not  be  slight,  lest  it  cast  off  before  a  due  degree  of 
adhesion  is  procured;  and  it  must  also  be  made  in  such  a  manner 
as  to  preserve  the  mouth  of  the  gut  as  free  and  as  open  as  may  be, 
upon  which  the  patient's  small  remaining  chance  does  in  some 
measure  depend.  The  method  advised  by  La  Peyronie,  of  stitch- 
ing the  mesentery  instead  of  the  intestine,  is  judicious  and  right. 

The  dressing  in  this  case  should  be  as  soft  and  as  light  as  pos- 
sible, nothing  heavy,  nothing  crammed  in,  nothing  which  can  ir- 
ritate or  give  pain;  and  the  patient  must  observe  the  most  rigid 
severity  of  diet,  and  the  most  perfect  quietude  both  of  body  and 
mind.  With  regard  to  medicine,  whatever  is  exhibited  must  be 
calculated  to  procure  rest  and  ease,  to  quiet  the  febrile  heat,  to 
keep  the  body  open,  and,  if  necessary,  (as  it  most  frequently  must 
be,)  to  resist  putrefaction.  All  the  rest  must  be  left  to  nature, 
who  is  by  her  great  Creator  furnished  with  such  powers,  as 
sometimes  to  produce  wonderful  effects,  even  in  these  deplorable 
cases. 


364  A  TREATISE  ON  RUPTURES. 

This  is  the  substance  of  the  best  practice,  and  of  the  most  ap- 
proved doctrine,  in  these  circumstances,  and  which  has  sometimes 
been  attended  with  a  fortunate  event;  but  the  practitioner  who  is 
so  situated  as  to  see  but  little  of  this  kind  of  business,  ought  to  be 
apprised  how  very  little  reason  there  is  to  hope  for,  or  to  promise 
success. 

More  censure  is  incurred  by  an  unguarded  prognostic,  than  by 
a  successful  event,  if  properly  and  judiciously  foretold;  and  if  a 
man  were  to  form  his  judgment  upon  this,  and  some  other  hazard- 
ous disorders,  from  books  only,  he  would  expect  very  little  of  that 
trouble  and  disappointment,  which  he  will  most  certainly  meet 
with  in  practice. 

Writers  in  general  are  too  much  inclined  to  tell  their  successes 
only,  and  are  fond  of  relating  cases  of  gangrene  and  mortification, 
in  which  large  portions  of  intestine  have  been  removed,  the  proper 
operations  performed  with  great  dexterity,  and  in  which  the  events 
proved  fortunate;  and  of  this  they  all  give  us  instances,  either  from 
their  own  practice,  or  that  of  others,  or  perhaps  sometimes  from 
imagination;  by  which  the  young  reader  is  made  too  sanguine  in 
his  expectation. 

That  these  extraordinary  successes  do  sometimes  happen,  is  be- 
yond all  doubt;  and  it  is  every  man's  duty  to  aim  at  the  same  by 
all  possible  means:  but  still  the  inexperienced  practitioner  should 
also  be  informed,  how  many  sink  for  one  that  is  recovered,  and 
how  many  favourable  circumstances  must  concur,  with  all  his 
pains,  to  produce  a  happy  event  in  these  ve.'-y  deplorable  cases. 
Without  this  caution,  he  will  meet  with  very  irksome  disappoint- 
ments; and,  having  been  often  baffled,  where  he  thought  he  had 
good  reason  to  expect  success,  he  will  sometimes  meet  with  it  so 
very  unexpectedly,  that  he  will  be  inclined  to  believe  the  sarcasti- 
cal  distinction  between  cures  and  escapes  not  ill-founded. 

To  say  the  truth,  the  hazard  is  so  great,  and  the  utmost  powder 
of  art  so  little,  that  what  lapis  said  to  iEneas  with  relation  to  his 
cure,  may  with  great  propriety  be  said  here: 

Non  hsec  humanis  opibus,  non  arte  magistra. 
Proveiiiunt ;  neque  te  .Enea  mea  dextera  servat ; 
Major  agit  Deus. 


A  TREATISE  ON  RUPTURES.  365 


SECT.  VIL 


The  portion  of  intestine,  or  omentum,  which  composed  an  her- 
nia, being  replaced  while  sound  and  unhurt  either  by  inflammation 
or  gangrene,  it  had  always  till  very  lately  been  supposed,  thai  if  a 
new  descent  of  them  were  prevented  by  the  immediate  application 
of  a  bandage,  no  mischief  would  be  likely  to  ensue;  and  that,  while 
the  iruss  executed  its  office  properly,  the  patient  would  be  thereby 
free  from  danger. 

But,  within  these  few  years,  it  has  by  some  of  the  French  writ- 
ers been  said,  that  the  hernial  sac  may  be  so  loose  and  unconnected 
with  the  spermatic  chord,  that  it  may  be  returned  into  the  belly, 
while  it  contains  a  portion  of  the  intestine,  labouring  under  a  stric- 
ture made  by  the  neck  of  the  said  sac;  and  of  this  they  have  given 
instances  of  cases — or  of  what  appeared  to  them  to  be  so. 

Mr.  Le  Dran  tells  us,  that,  in  one  of  these,  the  rupture  was  with 
some  difficulty  returned,  but,  the  symptoms  nevertheless  conti- 
nuing, the  patient  died;  and  that,  upon  opening  the  body,  he  found 
the  hernial  sac,  including  a  considerable  portion  of  intestine,  re- 
turned into  the  belly;  and  that  the  stricture  made  by  the  neck  of 
the  sac,  bound  so  tight,  that  he  could  not  disengage  the  gut  from  it 
without  cutting  it.     His  words  are: — 

"  Nous  trouvames  dans  le  ventre  le  sac  herniare,  qui  avoit  trois 
"  pouces  de  profondeur,  sur  huit  pouces  de  circonference,  et  dans 
"  ce  sac  etoit  encore  enfermee  une  demie  aulme  de  Pintestin 
"jejunum.  Tenant  le  sac  a  pleine  main,  je  voulus  en  faire  sortir 
"  Pintestin,  en  le  tirant  par  Pun  des  bouts;  mais  la  chose  me  fut 
"  impossible,  tant  Pentree  du  sac  etoit  reserree,  et  je  n'en  vins  au 
"  bout  qu'en  dilatant  cette  entree  avec  les  ciseaux,"  &c. 

In  De  la  Faye's  notes  on  Dionis,  may  also  be  seen  an  instance 
of  this  kind  of  case,  or  at  least  of  what  was  taken  for  such. 

I  have  already  given  my  opinion  concerning  the  practicability 
of  returning  a  hernial  sac  back  into  the  abdomen,  after  it  has  been 
out  any  considerable  length  of  time.  I  never  saw,  either  in  the 
dead  or  the  living,  any  reason  to  suppose  it  possible:  the  assertions 
of  these  gentlemen  are  very  positive,  and  I  must  leave  the  reader  to 
judge  of  them  as  he  can» 


366  A  TREATISE  ON  RUPTURES. 

The  straitness  of  the  neck  of  the  sac  is  supposed  to  be  produced 
by  the  pressure  of  ihe  bolster  of  a  truss,  worn  to  keep  the  parts  from 
descending.  This  part  of  the  supposition  is  probable:  but,  it  must 
also  be  considered,  that  the  same  pressure  must  almost  necessarily 
occasion  adhesions  of  the  ouiside  of  the  sac  to  the  surrounding 
cellular  membrane;  and,  if  we  were  to  suppose  the  sac  loose  and 
unconnected  in  every  other  part,  (a  thing,  I  must  own,  I  never 
saw,)  yet  this  alone  would  for  ever  prevent  its  return  into  the 
belly. 

It  is  indeed  represented  as  a  circumstance  not  very  frequently 
occurring,  which  is  fortunate  for  mankind;  as  it  can  neither  be 
foreseen  nor  prevented,  and  would  add  considerably  to  the  hazard 
of  ruptures. 

It  is  said,  that,  by  carefully  attending  to  the  manner  in  which 
a  rupture  goes  up,  we  may  distinguish  whether  the  sac  returns 
with  it  or  not;  that  if  it  does,  including  the  gut,  a  hard  body  will 
be  perceived  to  pass  under  the  finger,  and  that  the  intestine,  in  its 
passage  through  the  abdominal  opening,  will  not  make  that  kind 
of  guggling  noise  which  it  is  usuall)  found  to  do,  when  the  sac  does 
not  return  with  it.  This,  instead  of  being  the  characteristic  mark 
of  the  return  of  the  sac,  will  almost  always  be  found  to  be  the  case 
when  a  portion  of  omentum  which  has  been  much  compressed, 
goes  up  at  the  same  time  with  the  gut;  and  therefore,  however 
ingenious  this  observation  may  seem,  considered  theoretically,  it 
is  not  to  be  depended  upon  in  practice. 

But  supposing  we  had  some  clear  and  undoubted  marks,  by 
which  we  could  always  know  when  this  was  the  case,  1  do  riot 
see  how  we  could  avail  ourselves  of  them:  the  intestine  must  be 
returned  before  we  can  have  our  information;  and  if,  instead  of  the 
uncertain,  delusive  reasons  just  given,  we  had  the  clearest  and 
most  satisfactory  marks  of  what  is  suspected,  we  have  no  remedy. 
but  a  very  perplexing,  tedious,  and  painful  operation,  which,  I 
fancy,  as  few  surgeons  would  in  these  circumstances  choose  to 
perform  as  patients  submit  to 

I  call  these  marks  or  symptoms,  which  these  gentlemen  have 
given  us,  doubtful  and  delusive,  because  they  do  not  with  any 
degree  of  certainty  indicate  the  cause  to  which  they  are  owing,  or 
from  which  they  arise;  for  the  inflammation  excited  in  the  intes- 
tine by  its  having  been  engaged  lor  some  lime  in  a  stricture,  will 


A  TREATISE  ON  RUPTURES.  367 

sometimes  produce  all  the  same   complaints  after  its  return:  but 
no  chirurgical  operation  will  relieve  them. 

In  the  common  reduction  therefore  of  an  intestinal  rupture  by 
the  hand',  I  do  not  see  how  we  can  avail  ourselves  of  this  supposed 
discovery;  and  when  the  operation  by  the  knife  becomes  necessary, 
it  can  be  of  no  consequence  at  all;  for  if  the  operation  be  properly 
performed,  the  hernia!  sac  will  be  divided  through  its  whole  length, 
before  the  instrument  reaches  the  tendon;  arid  therefore  the  gut 
can  never  be  returned,  while  bound  by  any  stricture  from  the 
former. 

It  has  indeed  been  said,  that  till  this  discovery  was  made,  the 
stricture  of  the  abdominal  tendon,  and  the  adhesion  of  the  con- 
tents of  the  hernial  sac  to  its  sides,  were  the  only  known  reasons 
why  any  rupture  should  be  irreturnable;  and  that  when  such  case 
occurred,  if  the  tendon  only  was  divided,  and  the  sac  reduced 
unopened,  the  patient  might  .be  lost,  notwithstanding  all  that  had 
been  done.  To  this  I  can  only  say,  that  a  stricture,  made  by  the 
sac  only,  is  far  from  being  a  thing  unknown,  and  is  one  of  the 
principal  reasons  why  all  judicious  writers  and  practitioners  have 
advised  it  to  be  always  divided;  and  when  this  is  properly  execut- 
ed, no  such  consequences  can  follow,  even  if  the  hernial  sac 
should  be  (what  I  have  never  yet  seen)  capable  of  being  returned 
into  the  belly. 


SECT.  VIII. 


Ruptures  through  the  openings  of  the  tendons  of  the  oblique 
muscles  in  females  are  subject  to  the  samesjmptoms,  and  require 
nearly  the  same  general  treatment,  as  the  inguinal  ruptures  of 
males;  and,  like  them,  frequently  admit  of  perfect  cure,  if  not 
mismanaged  or  neglected  at  first:  the  same  kind  of  truss  is  also 
necessary,  and  the  same  cautions  with  regard  to  the  manner  of 
wearing  it. 

The  open  texture  of  the  cellular  membrane  surrounding  the 
spermatic  vessels,  and  the  laxity  of  the  scrotum,  render  the  hernial 


368  A  TREATISE  ON  RUPTURES. 

tumor  much  larger  in  males  than  it  can  well  be  in  females:  neither 
can  it  descend  so  low  in  the  latter,  as  it  does  frequently  in  the 
former,  for  reasons  which  are  obvious. 

The  female  hernia,  if  recent,  has  much  the  same  appearance 
as  the  bubonocele  in  man;  and  when  more  of  the  gut  or  caul  is 
thrust  forth  than  will  lie  conveniently  in  the  groin,  it  pushes  down 
into  one  of  the  labia  pudendi,  and  sometimes  forms  a  tumor  of 
pretty  considerable  size. 

When  easily  reducible,  like  that  of  men,  it  gives  but  little  pain, 
and  generally  returns  into  the  belly  upon  going  to  bed,  or  upon 
the  patient  being  laid  in  a  supine  posture.  When  it  is  bound  by 
the  opening  of  the  abdominal  tendon,  and  is  therefore  difficult,  or 
incapable  of  reduction,  it  is  attended  with  the  same  symptoms  as 
the  incarcerated  hernia  in  man,  and  requires  the  same  general 
treatment,  of  bleeding,  clysters,  purges,  warm  bath,  &c.  and  (these 
failing)  the  chirurgic  operation;  by  which  the  hernial  sac  is  laid 
open,  and  the  stricture  made  by  the  tendon,  divided. 

In  males,  the  cellular  membrane  which  surrounds  the  sperma- 
tic vessels  and  the  hernial  sac  is  generally  so  thickened  by  dis- 
tention, as  to  take  some  little  time  to  cut  through,  and  proves 
thereby  a  kind  of  security  to  prevent  the  sac  from  being  too 
hastily  opened;  but  in  females  it  should  be  remembered,  (hat  the 
hernial  bag  lies  immediately  under  the  membrana  adiposa,  and 
requires  to  be  very  cautiously  divided,  on  account  of  its  contents: 
nor  have  I  in  general  observed  the  fluid  contained  in  the  hernial 
sac  of  females  to  be  equal  to  that  which  is  found  in  males. 

The  piece  of  intestine  which  is  strangulated  in  the  female 
bubonocele  is  sometimes  so  small,  as  to  occasion  very  little  tumor; 
and  therefore,  if  recent,  is  very  often,  in  modest  women,  not 
known  to  be  the  cause  of  the  symptoms  which  it  produces.  If  by 
accident  it  returns  back  before  it  is  hurt  in  its  texture,  the  disease 
passes  for  a  colic;  if  it  proves  fatal  by  mortification,  it  is  taken  for 
a  passio  iliaca,  or  miserere.  The  means  made  use  of  for  the  relief 
of  either  of  those  diseases,  being  such  as  will  not,  in  general, 
without  the  assistance  of  a  surgeon's  hand,  procure  a  return  of 
the  protruded  gut,  many  an  useful  life  has  been  lost  by  the  real 
cause  of  the  mischief  not  being  known.  Every  symptom  (the 
tumor  excepted)   which  accompanies  a  rupture  labouring  under 


A  TREATISE  ON  RUPTURES.  369 

stricture,  may  attend  a  passio  iliaca;  that  is,  an  inflammation  and 
obstruction  to  the  execution  of  the  office  of  the  intestine,  whether 
produced  by  the  stricture  of  the  abdominal  tendon,  or  the  spas- 
modic contraction  of  its  own  muscular  fibres,  will  be  attended 
with  the  same  kind  of  symptoms:  but  though  the  general  means 
of  relief  are  alike  in  both  cases,  yet  the  former  requires  also  the 
assistance  of  a  surgeon's  hand  to  replace  the  piece  of  intestine,  or 
all  the  rest  will  be  absolutely  ineffectual:  if  that  be  neglected,  the 
case  in  general  will  end  ill,  and  though  the  mischief  is  set  to  ano- 
ther account,  and  supposed  to  have  been  without  remedy,  yet  it  is 
very  certain  that  timely  assistance  would  very  frequently  prevent 
such  bad  consequences.  It  therefore  behoves  every  medical  man, 
who  may  be  called  to  women  labouring  under  such  complaints,  to 
be  very  attentive  to  them;  and  if  the  symptoms  run  high,  never  to 
omit  inquiring  whether  there  be  any  tumor  in  the  groin,  belly,  or 
pudenda;  and  if  there  be  such,  to  be  informed  of  what  nature  it  is, 
before  he  goes  any  further,  or  loses  any  more  of  that  time,  which 
in  all  these  cases  is  so  very  precious. 

In  the  case  of  the  dolor  colicus,  the  pain  is  either  round  about 
the  navel,  or  diffused  in  general  all  over  the  belly:  that  arising 
from  i  strangulated  rupture  is  also  very  frequently  general  all  over 
the  belly,  but  is  always  more  particularly  acute  at  the  groin,  which 
part  is  also  remarkably  tender  to  the  touch.  The  tension  of  the 
belly,  and  the  vomiting  in  the  passio  iliaca,  are  in  general  the  first, 
at  least  they  are  very  early  symptoms;  whereas  they  do  not  come 
on  in  ruptures,  till  after  some  time  is  past.  Perhaps  some  other 
minute  distinctions  might  be  made  between  the  apparently  similar 
symptoms  of  the  two  diseases:  but  the  best  and  most  infallible 
way  to  know  what  the  real  state  of  the  ease  is,  and  thereby  what 
ought  to  be  done,  is  to  have  the  parts  examined  where  such  tumor 
may  be  expected.  This  removes  all  doubt,  and  gives  the  practi- 
tioner the  satisfaction  of  knowing,  that,  let  the  consequence  be 
whatever  it  may,  he  is  pursuing  a  rational  and  probable  method  of 
relieving  his  patient. 


VOL.  1. 


370  A  TREATISE  ON  RUPTUREi,'. 


SECT.  IX. 


The  crural,  or  femoral  hernia,  receives  its  name  from  its  situa- 
tion, tiie  tumor  occasioned  by  it  being  in  the  upper  and  fore  part 
of  the  thigh. 

To  understand  rightly  the  nature  and  situation  of  a  crural  rup- 
ture, it  is  necessary  to  attend  to  the  anatomical  structure  and  dis- 
position of  the  obliquus  descendens  .muscle  of  the  abdomen. 
Whoever  does  this,  will  find  that  that  part  of  it  which  runs  obli- 
quely downward  from  the  spine  of  the  os  ilion,  towards  the  sim- 
physis  of  the  os  pubis,  is  tucked  down,  and  folded  inward,  as  it 
were.  This  edge  or  border,  so  folded  in,  is  what  is  called  the 
ligamentum  Poupartii  by  some,  by  others  the  ligamentum  Fallopiij 
as  if  it  was  a  distinct  and  separate  body,  but  is  really  no  more 
than  the  inferior  border  of  the  tendon  of  the  oblique  muscle.  In 
all  the  space  between  these  two  attachments,  this  tendon  is  loose 
and  unconnected  with  any  bone.  All  the  hollow,  which  is  made 
by  the  form  of  the  os  ilion,  between  the  point  of  the  attachment  of 
the  ligament  or  tendon  to  that  bone,  and  its  other  connexion,  at  the 
os  pubis,  is  filled  up  by  cellular  membrane,  fat,  and  glands;  which 
parts  are  covered,  and  braced  down,  by  a  fine  tendinous  expansion, 
communicating  between  the  tendon  of  the  obiiquus  descendens 
abdominis  and  the  fascia  lata  of  the  thigh. 

Under  this  tendon,  or  ligament,  the  parts  composing  a  hernia 
pass,  and  produce  a  tumor  on  the  upper  and  fore  part  of  the  thigh. 
The  sac  is  generally  described  as  passing  over  the  crural  artery 
and  vein,  which  are  said  to  lie  immediately  behind  it;  but  whoever 
will  examine  the  state  of  these  parts  in  a  dead  subject,  will  find 
that  this  is  not  a  true  representation:  the  descent  is  made  on  one 
side  of  these  vessels,  nearer  to  the  os  pubis;  and  the  hernial  sac, 
if  it  be  not  greatly  distended,  lies  between  the  crural  vessels  and  the 
last  mentioned  bone,  on  which  it  rests. 

The  femoral  hernia  is  not  so  subject  to  stricture  as  the  inguinal, 
there  being  a  larger  space  for  the  intestine  to  occupy:  but  when 
such  mischief  does  happen,  the  symptoms  are  so  exactly  the  same 
as  they  are  in  a  strangulated  inguinal  hernia,  that  it  is  quite  uiine- 


A  TREATISE  ON  RUPTURES.  371 

ccssary  to  repeat  them  in  this  place.  The  method  of  attempting 
reduction,  and  the  treatment  of  the  patient  in  case  of  difficulty,  are 
the  same  also;  excepting  that,  in  the  inguinal,  tlic  part  to  be  reduc- 
ed should  be  pressed  obliquely  toward  the  os  ilion;  in  the  femoral, 
the  pressure  ought  to  be  made  directly  upward,  or  a  little  toward 
the  pubes. 

When  it  is  not  reducible  by  the  hand  only,  it,  like  the  other, 
becomes  the  object  of  a  chirurgic  operation,  by  which  the  sac  is 
laid  open,  the  stricture  removed,  and  the  prolapsed  parts  returned. 

The  incision  should  be  made  through  (he  skin,  and  membrana 
adiposa,  the  whole  length  of  the  tumor:  under  these  will  be  seen 
the  tendinous  fascia,  or  expansion,  and  immediately  under  that 
the  hernial  sac.  These  being  carefully  divided,  and  the  poriion 
of  intestine  thereby  denuded,  it  is  well  worth  while  to  try  if  it  can- 
not be  returned  without  dividing  the  tendon,  as  there  is  a  con- 
siderable space  between  the  os  ilium  and  the  os  pubis,  to  manage 
such  reduction  in,  and  as  the  division  of  the  tendon  is  not  always, 
in  this  kind  of  rupture,  so  safely  executed.  In  ihis  there  are  two 
parts  of  consequence,  which  lie  very  little  out  of  the  way  of  the 
knife,  and  which  an  operator  should  avoid  wounding:  these  are 
the  epigastric  artery,  and  the  spermatic  chord.  If  the  division  of 
the  ligament  be  made  directly  upward,  the  spermatic  chord  will 
certainly  be  divided;  and  if,  to  avoid  that,  the  knife  be  carried 
very  obliquely  towards  the  os  ilium,  the  artery  will  meet  with  the 
same  fate;  and  indeed  if  the  incision  of  the  ligament  be  made  of 
any  length,  let  it  be  made  in  whatever  part  it  may,  the  risk  will 
be  great  of  wounding  one  of  the  parts  just  mentioned,  as  will  ap- 
pear to  any  body  who  will  examine  them  in  situ  naturally  and 
make  a  proper  allowance  for  the  pressure  and  distention  of  the 
hernial  sac. 

Of  the  two,  the  spermatic  chord  is  certainly  the  most  to  be  re- 
garded, as  the  total  division  of  it  would,  in  all  probability,  render 
the  testicle  on  that  side  useless.  If  the  artery  be  wounded,  it  must 
be  taken  up  with  a  needle  and  ligature;  but  the  doing  is  not  so 
easy  as  the  directing  it  to  be  done:  the  epigasti"ic  artery  in  many 
men  is  near  as  large  as  the  smaller  carpal;  departs  immediately 
from  the  trunk  of  the  crural,  and,  at  its  origin,  lies  in  a  bed  of  fat 
and  cellular  membrane;  the  stream  of  blood  would  be  pretty  brisk,- 


3tJSI  A  TREATISE  ON  RUPTURES. 

and  the  passage  of  the  needle  round  would  certainly  be  trouble- 
some, if  not  hazardous,  from  the  vicinity  of  the  crural  vessels.  It 
may  undoubtedly  be  happily  executed;  but,  as  it  must  be  aaencied 
with  a  good  deal  of  trouble,  and  some  risk,  it  is  much  belter  to 
avoid  the  necessity,  which  I  think  may  always  be  done,  consider- 
ing the  large  space  between  the  os  ilion  and  the  os  pubis,  and  that 
the  space  is  occupied  principally  by  cellular  membrane  and  fat: 
or  if  the  division  of  the  ligament  be  unavoidable,  let  the  operator 
be  particularly  careful  to  keep  the  extremity  of  the  probe-pointed 
knife  within  the  end  of  his  fore-finger,  held  up  tight  just  behind 
the  edge  or  border  of  the  tendon,  and  to  make  as  small  an  incision 
as  may  be  necessary:  the  probe-scissors,  the  common  instrument 
in  use  for  this  operation,  is  in  this  case  particularly  hazardous  and 
improper. 

In  all  other  circumstances,  this  hernia,  and  the  inguinal,  are  so 
similar  as  to  need  no  repetition. 


SECT.  X. 


THE  CONGENIAL  HERNIA. 


The  congenial  hernia,  as  it  is  now  called,  is  that  particular 
kind  of  hernia,  in  which  the  portion  of  intestine,  or  omentum, 
which  occasions  the  tumor,  instead  of  being  found  alone  in  the 
hernial  sac,  (as  in  a  common  rupture,)  is  found  in  contact  with  the 
naked  testicle;  the  bag  containing  it  being  formed  by  the  tunica 
vaginalis  testis. 

The  manniMi  in  which  a  common  hernial  sac  is  formed,  has  al- 
ready in  a  former  chapter  been  related,  viz.  by  the  thrusiing  forth 
of  a  portion  of  the  peritoneum  though  the  opening  in  the  tendon 
of  the  external  oblique  musclf-  of  the  abdomen;  which  portion,  so 
thrust  forth,  contains  a  piece  of  intestine,  or  omentum,  or  both.  A 
hernial  sac  thus  formed,  always  communicates  with  the  caviiyof 
the  belly,  but  never  with  that  of  the  tunica  vaginalis  testis.     It 


A  TREATISE  ON  RUPTURES.  373 

passes  clown  anterior  to  the  spermatic  chord;  and,  when  it  is  laid 
optrMi,  is  found  to  contain  only  a  portion  of  gut,  or  caul,  and  a  small 
quantity  of  fluid. 

On  the  contrary,  the  sac  of  a  congenial  hernia  is  formed  by  the 
tunica  vaginalis  testis  itself;  and,  whf;n  it  is  laid  open,  (whatever 
else  may  be  in  it,)  it  is  always  found  to  contain  the  testicle, 
covered  only  by  its  proper  coat,  commonly  called  tunica  al- 
buginea. 

The  manner  in  which  this  is  brought  about,  the  original  or  early 
situation  of  the  testes  in  a  foetus,  their  descent,  their  protrusion  from 
the  cavity  of  the  belly,  and  the  formation  of  the  tunica  vaginalis 
testis,  I  have  described  so  much  at  large  in  two  tracts  already 
published,^  that  I  shall  give  a  very  short  account  of  them  in  this 
place. 

That  bag  which  is  designed  to  make  the  future  tunica  vaginalis 
testis,  is  an  originally  formed  part,  lies  in  the  groin,  under  the  skin- 
and  adipose  membrcyie,  and  has  an  orifice  always  open  to  the  ab- 
domen of  a  foetus.  By  means  of  this  orifice,  the  testicle  at  proper 
time  descends  into  the  groin  first,  and  then  most  commonly  into 
the  scrotum;  and,  when  it  has  been  some  little  time  in  the  latter, 
the  opening  from  the  belly  generally  becomes  close,  and  is  oJiIite- 
rated.  Bv  the  closing  of  this  passage,  a  bag  or  cavity  is  formed, 
which  contains  within  it  the  testicle,  covered  only  by  its  tunica 
albuginea,  and  which  bag  never  afterward  has  any  communication 
with  the  orifice  into  the  cavity  of  the  belly. 

The  time  at  which  the  testicles  are  thrust  forth  from  the  belly  is 
very  uncertain,  as  I  have  often  experienced;  and  so  is  that  of  the 
absolute  closing  of  the  sacculus.  In  some  they  pass  out  before  birth, 
in  some  immediately  after,  and  in  some  not  till  som_e  time  after;  in 
some  they  never  pass  out  at  all,  and  in  others,  they  (that  is,  the 
two)  arrive  in  the  groin,  or  scrotum,  at  different,  and  sometimes 
very  distant  times.  In  short,  the  intention  of  nature,  and  her  pro- 
cess, is  in  general  regular  and  plain,  but  it  is  accomplished  at  dif- 

"  An  Account  of  the  Congenial  Hernia,  published  in  1757  ;  and  some  Ob- 
servations on  the  Hydrocele,  published  in  1762.  In  Dr.  Hunter's  Medical 
Comment,  No.  1,  may  also  be  seen  a  very  ingenious  account  of  tliis  matter,  by 
his  brother  Mr.  John  Hunter, 


374  A  TREATISE  ON  RUPTURES. 

ferev)f  periods  in  different  persons;  and  sometimes,  like  most  other 
parts  of  the  animal  economy,  it  is  totally  prevented  by  accident,  or 
malformation. 

The  intrusion  of  a  piece  of  intestine,  or  omentum,  into  the  ori- 
fice of  the  tunica  vaginalis,  is  one  of  these  accidents.  By  means 
of  either  of  these,  the  closing  of  the  passage  is  prevented,  and  a 
hernial  sac  of  a  particular  kind  formed.  This  sac  being  really  the 
vaginal  coal  of  the  testis,  must,  if  that  body  has  fallen  from  the 
abdomen,  contain  the  intestine,  omentum,  or  whatever  forms  the 
hernia  and  the  testicle  in  immediate  contact  with  each  other. 

This  is  the  congenial  hernia;  a  disease  unknown  till  within  these 
few  years,  but  by  no  means  an  infrequent  one. 

The  appearance  of  a  hernia  in  very  early  infancy  will  alwa3'S 
make  it  probable  that  it  is  of  this  kind;  but  in  an  adult,  there  is 
no  reason  for  supposing  his  rupture  to  be  of  this  sort,  but  his  hav- 
ing been  afflicted  with  it  from  his  infancy:  there  is  no  external 
mark  or  character,  whereby  it  can  be  certainly  distinguished  from 
one  contained  in  a  common  hernial  sac;  neither  would  it  be  of 
any  material  use  in  practice  if  there  was. 

When  reiurnable,  it  ought  like  all  other  kind  of  ruptures  to  be 
reduced,  and  constantly  kept  up  by  a  proper  bandage;  and  when 
attended  with  symptoms  of  slricture,  it  requires  the  same  chirurgic 
assistance  as  the  common  hernia. 

In  very  young  children,  there  are  some  circumstances  relative 
to  this  kind  of  rupture,  which  are  very  well  worth  attending  to, 
as  they  may  prove  of  very  material  consequence  to  the  patient. 

A  piece  of  intestine,  or  omentum,  may  get  pretty  low  down  in 
the  sac,  while  the  testicle  is  still  in  the  groin,  or  even  within  the 
abdomen;  both  which  I  have  seen.  In  this  case,  the  application 
of  a  truss  would  be  highly  improper;  for  in  the  latter,  it  might 
prevent  the  descent  of  the  testicle  from  the  belly  into  the  scrotum: 
in  the  former  it  must  necessarily  bruise  and  injure  it,  give  a  great 
deal  of  unnecessary  pain,  and  can  prove  of  no  real  use.  Such 
bandage  therefore  ought  never  to  be  applied  on  a  rupture  in  an 
infant,  unless  the  testicle  can  be  fairly  felt  in  the  scrotum,  after 
the  gut  or  caul  is  replaced;  and  when  it  can  be  so  felt,  a  truss  can 
never  be  put  on  too  soon. 

As  this  kind  of  rupture  is  subject  to  stricture  with  all  its  con- 


A  TREATISE  ON  RUPTURES.  375 

sequences,  as  much  as  that  wliicli  is  contained  in  a  common  her- 
nial sac,  and  therefore  liable  to  stand  in  need  of  the  chirurgic 
operation:  it  may  be  very  well  worth  an  operator's  while  to  know, 
that  an  old  rupture,  which  was  originally  congenial,  is  subject  to 
a  stricture  made  by  the  sac  itself,  independent  of  the  abdominal 
tendon,  as  well  as  to  that  made  by  the  said  tendon. 

Whether  this  be  owing  to  the  weight  of  the  tesiicle  at  the  bot- 
tom of  the  sac,  and  the  endeavours  which  nature  makes  to  close 
the  upper  part  of  the  tunica  vaginalis,  or  to  what  other  cause,  I 
will  not  pretend  to  say;  but  the  fact  I  have  several  times  noticed, 
both  in  the  dead  and  in  the  living.  1  have  seen  such  stricture 
made  by  the  sac  of  oneof  these  hernise,  as  produced  all  those  bad 
symploms  wiiich  render  the  operation  necessary;  and  I  have  met 
with  two  diiferent  strictures,  at  near  an  inch  distance  from  each 
other,  in  the  body  of  a  dead  boy  about  fourteen,  one  of  which 
begirt  the  intestine  so  tight  that  I  could  not  disengage  it  without 
dividing  the  sac. 

In  this  kind  of  hernia  I  have  also  more  frequently  found  con- 
nexions and  adhesions  of  the  parts  to  each  other,  than  in  the  com- 
mon one;  but  there  is  one  kind  of  connexion  sometimes  met  with 
in  the  congenial  hernia,  which  can  never  be  found  in  that  which 
is  in  a  common  hernial  sac,  and  which  may  require  all  the  dex- 
terity of  an  operator  to  set  free;  I  mean  that  of  the  intestine  with 
the  testicle,  from  which  I  have  more  than  once  experienced  a  good 
deal  of  trouble. 

When  a  common  hernial  sac  has  been  laid  open,  and  the  intes- 
tine and  omentum  have  been  replaced,  there  can  be  nothing  left  in 
it  which  can  require  particular  regard  from  the  surgeon;  but  by 
the  division  of  the  sac  of  a  congenial  hernia,  the  testicle  is  laid 
bare,  and  after  the  parts  composing  the  hernia  have  been  reduced, 
will  require  great  regard  and  tenderness,  in  all  the  future  dress- 
ings, as  it  is  a  part  very  irritable,  and  very  susceptible  of  pain,  in- 
flammation, &c.^ 

3  The  method  of  bringing'  the  parts  together,  and  retaining  them  so  as  to 
exclude  the  air,  (mentioned  in  a  former  note,  in  this  volume,)  is  equally  ap- 
plicuble  to  cases  of  congenial  hernix  ;  and  as  it  will  prevent  tlie  exposure  of 
the  testis,  all  future  dressings  of  it  will  he  unnecessar}'. 


$76  A  TREATISE  ON  KUPTUREfe', 

If  a  large  quantity  of  fluid  shoul(3  be  collected  in  the  sac  of  a 
congenial  hernia,  and,  by  adhesions  and  connexions  of  the  parts 
within,  the  entrance  into  it  from  the  abdomen  should  be  totally 
closed,  (a  case  which  I  have  twice  seen,)  the  tightness  of  the 
tumor,  the  difficulty  of  distinguishing  the  testicle,  and  the  fluctua- 
tion of  the  fluid,  may  occasion  it  to  be  mistaken  for  a  common 
hydrocele;  and  if,  without  attending  to  other  circumstances,  but 
trusting  merely  to  the  feel  and  look  of  the  scrotum,  a  puncture  be 
hastily  made,  it  may  create  a  great  deal  of  trouble,  and  possibly  do 
fatal  mischief. 

By  what  has  fallen  within  my  observation,  I  am  inclined  to 
believe  that  the  sac  of  a  congenial  hernia  is  very  seldom,  if  ever, 
distended  to  the  degree  which  a  common  hernial  sac  often  is:  it 
also,  from  being  less  dilated,  and  rather  more  confined  by  the 
upper  part  of  the  spermatic  process,  generally  preserves  a  pyriform 
kind  of  figure,  and,  for  the  same  reason,  is  also  generally  ihinnerj 
and  will  therefore  require  more  attention  and  dexterity  in  an  ope- 
rator when  he  is  to  open  it.  To  which  I  believe  I  may  add,  that 
common  ruptures,  or  those  in  a  common  sac,  are  generally  gradually 
formed;  that  is,  they  are  first  inguinal,  and  by  degrees  become 
scrotal:  but  the  congenial  are  seldom,  if  ever,  remembered  by  the 
patient  to  have  been  in  the  groin  only. 


SECT.  XI. 


EXOMPHALOS. 


The  Exomphalos,  or  Umbilical  rupture,  is  so  called  from  its 
situation,  and  has,  like  the  other,  for  its  general  contents,  a  por- 
tion of  intestine,  or  omentum,  or  both.  In  old  umbilical  ruptures, 
the  quantity  of  omentum  is  sometimes  very  great. 

Mr.  Ranby  says,  that  he  found  two  ells  and  a  half  of  intestine  in 
one  of  these,  with  about  a  third  part  of  the  stomach,  all  adjiering 
together. 


A  TREATISE  ON  RUPTURES.  377 

Mr.  Gay  and  Mr.  Nourse  found  the  liver  in  the  sac  of  an  umlji- 
lical  hernia;  and  Bohnius  says  that  he  did  also. 

But  whatever  are  the  contents,  they  are  originally  contained 
in  the  sac,  formed  by  the  protrusion  of  the  periioneum. 

In  recent,  and  small  ruptures,  this  sac  is  very  visible;  bu*  in 
old,  and  large  ones,  it  is  broken  through  at  the  knot  of  the  n.vel, 
by  the  pressure  and  weight  of  the  contents,  and  is  not  always  to. 
be  distinguished;  which  is  the  reason  why  it  has  by  some  been 
doubted  whether  this  kind  of  rupture  has  a  hernial  sac  or  nol. 

Infants  are  very  subject  to  this  disease,  in  a  small  degree,  from 
the  separation  of  the  funiculus;  but  in  general  they  either  gel  rid 
of  it  as  they  gather  strength,  or  are  easily  cured  by  wearing  a  pro- 
per bandage.  It  is  of  still  more  consequence  to  get  this  disorder 
cured  in  females,  even  than  in  males,  that  its  retuin,  when  they  ■ 
are  become  adult,  and  pregnant,  may  be  prevented  as  much  as 
possible;  for  at  this  time  it  often  happens,  from  the  too  great  dis- 
tention of  the  belly,  or  from  unguarded  motion  when  the  parts  are 
upon  the  stretch.  During  gestation  it  is  often  very  troublesome; 
but  after  delivery,  if  the  contents  have  contracted  no  adhesion, 
they  will  ofteti  return,  and  may  be  kept  in  their  place  by  a  proper 
bandage. 

If  such  bandage  was  always  put  on  in  time,  and  worn  con- 
stantly, the  disease  might  in  general  be  kept  within  moderate 
bounds,  and  some  of  the  very  terrible  consequences  which  often 
attend  it  might  be  prevented.  The  woman  who  has  the  smallest 
degree  of  it,  and  who  from  her  age  and  situation  has  reason  to 
expect  children  after  its  appearance,  should  be  particularly  care- 
ful to  keep  it  restrained. 

In  some  the  entrance  of  the  sac  is  large,  and  the  parts  easily 
reducible;  in  others  they  are  difficult,  and  in  some  absolutely  ir- 
reducible. Of  the  last  kind  many  have  been  suspended  for  years 
iii  a  proper  bag,  and  have  given  little  or  no  trouble.  They  who 
are  afflicted  with  this  disorder,  who  are  advanced  in  life,  and  in 
whom  it  is  large,  are  generally  subject  to  colics,  diarrhoeas,  and, 
if  the  intestinal  passage  be  at  all  obstructed,  to  very  troub-esorae 
vomitings.-     It  therefore  behoves  such  to  take  care  to  keep  that 

^  On  Mihich  account  they  are  often  supposed  to  labour  under  a  Rtriottire  nf 
the  intestine,  when  tbey  reallv  do  no^ 
VOL.  J.  3  8 


376  A  TREATISE  UN  RUPTORES. 

tube  as  clean  and  free  as  possible,  and  neither  to  eat  nor  drink  any 
thing  likely  to  make  any  disturbance  in  that  part. 

The  cure,  as  proposed  by  authors,  is  either  radical  or  pal- 
liative. 

Celsus,  Paulus  iEgineta,  Albucasis,  Aquapendens,  Guido,  Se- 
verlnus,  Roland  us,  and  others,  mention  a  radical  cure  by  ligature: 
Fab.  ab  Aquapendente  proposes,  "  aut  medicamentis  aut  ferro 
*'  umbilicum  adurere;"  but  after  having  described  both  methods, 
lie  lays  them  under  such  restraints,  from  age,  habit,  size  of  the 
tumor,  time  of  the  year,  &,c.  as  amounts  almost  to  a  prohibition 
against  putting  them  in  practice  at  all;  and  it  is  to  be  hoped  that 
nobody  will  attempt  to  revive  them. 

The  methods  by  ligature  are  two;  in  the  one,  the  skin  covering 
the  tumor  is  to  be  lifted  up  with  the  finger  and  thumb,  or  with  a 
small  hook  to  free  it  from  the  intestine  underneath;  and  then  a 
ligature  is  to  be  made  round  the  basis  of  the  tumor,  so  strict  as  to 
procure  a  mortification  of  all  that  part  which  is  anterior  to  such 
ligature.  In  the  other,  the  skin  is  to  be  elevated  in  the  same 
manner,  and  a  needle  armed  with  a  double  ligature  is  to  be  passed 
through  the  basis  of  the  tumor,  which  is  to  be  tied  above  and  be- 
low, or  on  each  side,  so  tight  as  to  produce  the  same  effect.  Pre- 
vious to  the  drawing  the  ligature  close,  it  is  advised  to  make  a 
small  incision  in  the  top  of  the  tumor,  large  enough  to  pass  in  the 
end  of  the  fore-finger,  and  with  it  so  to  depress  the  intestine  or 
omentum,  as  to  prevent  their  being  engaged  in  the  stricture. 

The  intention  in  both  these  methods  is  the  same;  viz.  by  de- 
stroying the  lax  skin  covering  the  top  of  the  tumor,  to  produce  a 
cicatrix  which  shall  bind  so  tight  as  to  restrain  the  parts  from  any 
future  protrusion. 

The  objections  to  either  of  them  are  so  obvious,  that  it  is  hardly 
necessary  to  say  any  tiling  concerning  them;  though,  in  this  age  of 
quackery  and  credulity,  I  should  not  wonder  to  see  them  revived 
and  practised. 

In  young  subjects,  and  small  hernias,  a  bandage  worn  a  proper 
time  generally  proves  a  perfect  cure;  and  in  old  persons,  and 
large  tumors,  it  is  hardly  to  be  supposed  that  any  body  can  think 
of  any  but  a  palliative  one,  the  hazard  of  producing  a  mortifica- 
tion being  so  great. 


A  TREATISE  ON  RUPTURES.  379 

But  suppose  the  subject  to  be  young,  and  the  tumor  of  such  size 
and  in  such  state  as  to  make  it  unUiaHly  that  a  bandage  would  do 
more  than  palliate;  that  the  skin  covering  the  tumor  is  so  lax,  as 
to  make  it  improbable  that  it  should  ever  recover  its  former  state, 
and  lie  smooth;  and  that,  when  it  has  been  removed,  the  cicatrix 
shall  bind  so  tight,  as  to  prevent  the  future  protrusion  of  any  of 
the  contained  parts;  yet  who  can  tell  what  may  be  the  conse- 
quence of  this  destruction  of  parts,  and  this  indilatability  of  the 
skin  in  a  state  of  pregnancy?  I  mention  this,  because  I  have  seen 
very  terrible  mischief  from  the  bursting  of  a  cicatrix  on  the  navel, 
during  gestation;  though  the  scar  was  from  an  abscess,  opened  by 
incision,  and  consequently  could  not  be  supposed  to  be  equal,  either 
in  size  or  resistance,  to  one  produced  by  the  fore  mentioned  ope- 
ration. 

The  umbilical,  like  the  inguinal  hernia,  becomes  the  subject  of 
chirurgic  operation,  when  the  parts  are  irreducible  by  the  hand 
only,  and  are  so  bound  as  to  produce  bad  symptoms.  But  though 
I  have  in  the  inguinal  and  scrotal  hernia  advised  the  early  use  of 
the  knife,  I  cannot  press  it  so  much  in  this;  the  success  of  it  is 
very  rare,  and  I  should  make  it  the  last  remedy.  Indeed  I  am 
much  inclined  to  believe,  that  the  bad  symptoms  which  attend 
these  cases  are  most  frequently  owing  to  disorders  in  the  intestinal 
canal,  and  not  so  often  to  a  stricture  made  on  it  at  the  navel  as 
is  supposed.  I  do  not  say  that  the  latter  does  not  sometimes  bap- 
pen — it  certainly  does;  but  it  is  often  believed  to  be  the  case  when 
it  is  not. 

When  the  operations  become  necessary,  it  consists  in  dividing 
the  skin  and  hernial  sac,  in  such  manner  as  shall  set  the  intestine 
free  from  stricture,  and  enable  the  surgeon  to  return  it  into  the 
abdomen,  if  found,  and  not  adherent;  but  if  it  be  gangrenous,  or 
mortified,  the  altered  part  must  be  removed,  and  the  faecal  dis- 
charge be  derived  through  the  wound;  by  which  means,  some 
few  have  preserved  their  lives,  if  such  state  can  be  called  living. 


380  A  TREATISE  ON  RUPTURES. 

t 

SECT.  XII- 

VENTRAL  HERNIA,  &t. 

This  may  appear  in  almost  any  point  of  the  fore  part  of  tlie 
belly,  but  is  most  frequently  found  in  or  between  the  recti  mus- 
cles. 

The  portion  of  intestine,  &c.  is  always  contained  in  a  sac, 
made  by  the  protrusion  of  the  peritoneum.  When  reduced,  it 
should  be  kept  in  its  place  by  bandage;  and  if  attended  with 
stricture,  which  cannot  otherwise  be  relieved,  that  stricture  must 
be  carefully  divided. 

The  hernia  foraminis  ovalis  I  have  never  seen.'= 

All  the  parts  almost  which  are  contained  in  the  belly  or  pelvis, 
are,  by  the  dilation  of  iheir  connecting  membranes,  capable  of 
being  thrust  forth,  and  of  producing  swellings,  all  which  are  called 
herniaB. 

Ruysch  gives  an  account  of  an  impregnated  uterus  being  found 
on  the  outside  of  *he  abdominal  opening;  and  so  does  Hildanus 
and  Sennertus.  Ruysch  also  gives  an  account  of  an  entire  spleen 
having  passed  the  tendon  of  the  oblique  muscle.  And  I  have 
myself  seen  the  ovaria  removed  by  incision,  after  they  had  been 
some  months  in  the  groin. 

The  urinary  bladder  is  also  liable  to  be  thrust  forth,  from  its 
proper  situation,  either  through  the  opening  in  the  oblique  muscle, 
like  the  inguinal  hernia,  or  under  Poupart's  ligament,  in  the 
same  manner  as  the  femoral. 

This  is  not  a  very  frequent  species  of  hernia,  but  does  happen, 
and  has  as  plain  and  determined  a  character  as  any  other. 

It  has  been  mentioned  by  Bartholin,  T.  Dom.  Sala,  Platerus, 

e  Since  Mr.  P.  wrote  this,  be  informed  me  that  he  had  seen  two  cases  of  this 
kind,  one  in  a  man,  another  in  a  woman;  in  botli,  the  pai-ties  suffered  great 
pain  when  the  intestine  was  protruded,  as  it  frequently  was  to  the  size  of  a 
hen's  egg,  but  by  lying  in  a  horizontal  posture,  and  a  gentle  pressure  being 
made,  it  receded.    E. 


A  TREATISE  ON  RUPtURES.  381 

Bonetus,  Ruysch,  Petit,  Mery,  Verciier,  &c.  In  one  of  the  histo- 
ries given  by  the  latter,  the  urachus,  and  ini|)ervious  umbilical 
artery  on  the  left  side,  were  drawn  through  the  tendon  into  the 
scrotum,  with  the  bladder;  in  another  he  found  four  calculi. 

Ruyscb  gives  an  account  of  one  complicated  with  a  mortified 
bubonocele.  Mr.  Petit  says  he  felt  several  calculi  in  one,  which 
were  afterwards  discharged  through  the  urethra. 

Bartholin  speaks  of  T.  Dom.  Sala  as  the  first  discoverer  of  the 
disease,  and  quotes  a  case  from  him  in  which  the  patient  had  all 
the  symptoms  of  a  stone  in  his  bladder:  the  stone  could  never 
be  felt  by  the  sound,  but  was  found  in  the  bladder  (which  had 
passed  into  the  groin)  after  death .'* 

As  the  bladder  is  only  covered  in  part  by  the  peritoneum,  and 
must  insinuate  itself  between  that  membrane  and  the  oblique 
muscle,  in  order  to  pass  the  opening  in  the  tendon,  it  is  plain  that 
the  hernia  cystica  can  have  no  sac;  and  that,  when  complicated 
with  a  bubonocele,  that  portion  of  the  bladder  which  forms  the 
cystic  hernia  must  lie  between  the  intestinal  hernia  and  the  sperma- 
tic.chord;  that  is,  the  intestinal  hernia  jnust  be  anterior  to  the  cystic, 

A  cystic  hernia  may  indeed  be  the  cause  of  an  intestinal  one; 
for  when  so  much  of  the  bladder  has  passed  tlie  ring  as  to  drag 
in  the  upper  and  hinder  part  of  it,  the  peritoneum  which  covers 
that  part  must  follow,  and  by  that  means  a  sac  be  formed  for  the 
reception  of  a  portion  of  gut  or  caul.  Hence  the  different  situa- 
tion of  the  two  hernice  in  the  same  subject. 

<•  Many  years  ago  a  boy,  about  ten  years  of'ag'e,  was  siiov.'n  to  jMv.  PoU, 
with  a  hard  incompressible  tumor  in  the  upper  part  of  the  scrotum  on  the 
right  side,  which  gave  little  pain  except  when  pressed  on.  To  determine 
positively  its  nature  and  contents  was  certainly  a  matter  of  no  little  diffl'.ult* , 
It  however  occurred  to  me  that  it  might  be  a  hernia  of  the  bladder  includinc; 
a  stone.  Mr.  Pott  made  an  incision  through  the  skin  and  cellular  membrane 
on  the  upper  part  of  the  tumor,  which,  now  being  denudated,  more  plainly 
appeared  to  be  what  I  had  suspected.  Mr.  Polt  then  drew  it  forward  and 
divided  the  neck,  when  a  stone  of  the  size  of  a  very  large  nutmeg  was  de- 
tached covered  with  the  bladder,  except  at  the  upper  part,  which  was  left 
bare  from  the  elastic  retraction  of  the  bladder.  Some  urine  followed,  and 
continued  to  come  away  in  smaller  and  smaller  quantities  ihrougli  the  open- 
ing, till  it  completely  closed,  which  happened  in  a  few  days: — without  any 
adverse  symptoms,  the  boy  got  perfectly  well.  Tlie  stone  with  its  covering 
of  bladder  is  now  in  my  possession.    E. 


382  A  TREATISE  ON  RUPTURES. 

While  recent,  this  kind  of  hernia  is  easily  reducible,  and  may, 
like  the  others,  be  kept  within  by  a  proper  bandage;  but  when  it  is 
of  any  dale,  or  has  arrived  to  any  considerable  size,  the  urine 
cannot  be  discharged,  without  lifting  up,  and  compressing  the 
scrotum:  the  outer  surface  of  the  bladder  is  now  become  adherent 
to  the  cellular  membrane,  and  the  patient  must  be  contented  with 
a  supensory  bag. 

In  the  case  of  complication  with  a  bubonocele,  if  the  operation 
becomes  necessary,  great  care  must  be  taken  not  to  open  the 
bladder  instead  of  the  sac,  to  which  it  will  always  be  found  to  be 
posterior.  And  it  may  also  sometimes  by  the  inattentive  be  mis- 
taken for  a  hydrocele,  and,  by  being  treated  as  such,  may  be  the 
occasion  of  great  or  even  fatal  mischief. 


SECT.  XIII. 


ATTEMPTS  TOWARDS  A  RADICAL  CURE. 

In  the  first  section  of  this  treatise  I  have  said,  that  the  means 
used  to  obtain  both  a  palliative  and  a  radical  cure  were  exactly 
the  same,  and  the  event  was  dependent  on  many  circumstances, 
which  a  surgeon  could  neither  direct  nor  alter;  such  as  the  age  of 
the  patient,  the  date  of  the  hernial  sac,  the  size  of  the  abdominal 
openings,  &c. 

They  who  are  unacquainted  with  the  true  nature  of  this  disease 
may  possibJy  be  surprised  at  this  assertion,  and  be  thereby  induced 
to  believe,  what  has  in  all  times  been  so  confidently  asserted,  viz. 
that  there  are  methods  and  medicines  whereby  this  disease  may 
always  be  perfectly  cured;  and  that  the  surgeons,  either  through 
indolence  will  not  get  information  of  them,  or  through  obstinacy 
will  not  practise  them.  If  either  of  these  charges  was  true,  it 
must  be  the  latter,  for  we  certainly  do  know  what  attempts  of  this 
kind  have  been  made;  and  if  any  of  these  means  had  really  de- 
served the  character  which  has  been  given  of  them,  had  been  safely 


A  TREATISE  ON  RUPTURES.  383 

practicable,  or  had  proved  generally  successful,  I  should  certainly 
have  spoken  of  them  in  their  proper  place:  but  this  is  so  far  from 
being  the  case,  that,  on  the  contrary,  however  they  may  have  been 
applauded  by  a  few  individuals,  they  have,  upon  repeated  expe- 
riment, been  found  unfit  for  general  practice,  being  either  totally 
inefficacious,  or  painfully  mischievous.  The  majority,  nay,  al- 
most all  they  who  have  submitted  to,  or  tried  them,  have  remained 
uncured  of  their  disease,  or  have  been  mutilated  or  murdered  in 
the  attempt. 

Several  of  these  methods  have  indeed  the  sanction  of  antiquity, 
and  have  been  described  and  even  practised  by  many  of  the  old 
surgeons:  the  principal  of  these,  or  they  which  are  most  worthy  of 
notice,  are  the  cure  by  cautery;  the  cure  by  caustic;  that  by  castra- 
tion; the  punctum  aureum;  the  royal  stitch;  and  the  cure  by  in- 
cision. 

In  Avicenna,  Albucasis,  Paulus  iEgineta,  Fab.  ab  Aquapen- 
dente,  Guido,  De  Caliaco,  Severinus,  Theodoric,  Rolandus,  Ser- 
jeant Wiseman,  and  others,  will  be  found  the  cure  by  cautery^ 
which  is  performed  as  follows: 

After  a  proper  time  spent  in  fasting  and  purging,  the  patient 
must  be  put  into  an  erect  posture,  and  by  coughing,  or  sneezing, 
is  to  make  the  intestine  project  in  the  groin  as  much  as  possible; 
when  the  place  and  circumference  of  such  projection  is  to  be 
marked  out  with  ink.  Then  the  patient  being  laid  on  his  back, 
the  intestine  is  to  be  returned  fairly  into  the  belly,  and  a  red  hot 
cautery  is  to  be  applied  according  to  the  extent  of  the  marked  line. 
For  this  purpose,  cauteries  of  different  sizes,  shapes,  and  figures, 
have  been  devised;  annular,  elliptical,  circular,  like  the  Greek 
letter  Gamma,  &c.  The  writers  who  have  given  an  account  of 
this  operation,  have  differed  a  good  deal  from  each  other,  not  only 
in  the  size  and  figure  of  the  cautery,  but  in  depth  of  its  effect- 
Some  have  directed  it  to  be  repeated,  so  as  to  denude  the  os  pubis; 
others  direct  that  the  skin  only  be  destroyed  by  the  iron,  the  cel- 
lular membrane,  sac,  periosteum,  &c.  with  repeated  escharotic 
applications.  .  But,  in  all  of  them,  the  exfoliation^  of  the  bone  is 

=  Albucasis  says,  "Et  sciasquod  quanclo  tu  non  conseqneris  os  cum  caufe- 
"  no,  non  confert  operatio  tua." 


384  A  TREATISE  ON  RUPTURES. 

made  a  necessary  part  of  the  process.  The  eschar  and  sloughs 
being  separated,  and  the  exfoliation  cast  off,  the  palieiil  is  ordered 
to  observe  an  extremely  strict  regimen,  to  lie  on  his  back  during 
the  cure,  and  to  wear  a  bandage  for  some  time  after,  in  order  to 
prevent  a  new  descent  of  the  parts,  which,  notwithstanding  all 
the  pain,  and  all  the  hazard,  the  patient  had  undergone,  he  was 
still  liable  to. 

The  cure  by  caustic  seems  to  have  succeeded  to  that  by  cautery, 
and  is  described  by  most  of  the  same  writers,  particularly  by 
Guido,  Severinus,  Lanfranc,  Parey,  Theodoric,  Scultetus,  &c. 

The  patient  being  laid  on  his  back,  and  the  paris  returned  into 
the  belly,  a  piece  of  caustic  is  to  be  applied  on  the  skin,  covering 
the  opening  in  the  abdominal  tendon,  so  large  as  to  produce  an 
eschar,  about  the  size  of  half  a  crown. 

Some  suffer  this  eschar  to  separate,  others  divide  it,  and  then,  by 
the  repeated  applications  of  escharotics,  destroy  the  membrana 
cellularis,  with  as  much  of  the  hernial  sac  as  can  be  done  without 
injuring  the  spermatic  vessels.  For  this  purpose,  different  kinds 
of  corrosive  applications  have  been  made  use  of:  pastes  loaded 
with  sublimate  or  arsenic;  the  stirpes  brassicae,  burnt;  the  tithy- 
malus;  the  lapis  infernalis  alone,  or  with  suet  and  opium;  oil  of 
vitriol;  with  many  others,  according  to  the  humour  of  the  operator. 
But,  though  the  means  are  somewhat  different  from  each  other, 
thte  end  or  intention  in  the  use  of  them  all  is  the  same,  viz.  to  re- 
move or  destroy  the  skin  and  cellular  membrane  covering  the  tu- 
mor, together  with  a  part  of  the  hernial  sac,  and  by  that  means  to 
procure  such  an  incarnation,  as,  by  its  firmness,  and  its  attachment 
to  the  bone  and  parts  adjacent,  shall  prevent  a  new  descent  of 
either  gut  or  caul. 

The  mere  relation  of  one  of  these  methods  is  sufficient  to  shock 
any  humane  or  ingenuous  man.  The  horror  attending  the  use  of 
the  cautery  must  be  great,  to  say  nothing  of  the  extreme  uncer- 
tainty of  the  size  or  depth  of  the  eschar:  the  apprehension  from 

Rolandiis  orders  the  cautery  to  be  used  in  the  same  manner  ;  so  do  Guido, 
Theodoric,  &.c. 

Bruniis  says,  "  Si  non  fiierit  os  consccutum,  in  pviir  a  -ire,  tunc  itera caute- 
"rium  vice  ah4  d^)ne&  conseqiieris  ;  quia  si  noii  coaseculuni  fuerit  os,  cum 
"cauterio,  panrnj  confert  operatio  tuu." 


A  TREATISE  ON  RUPTURES.  385 

the  caustic  will  be  less,  incieeci,  but  the  pain  must  be  nearly  as 
great,  and  of  much  longer  duration. 

The  parts  to  be  destroyed  are,  as  I  have  just  said,  the  skin,  the 
membrana  adiposa,  part  of  the  hernial  s«c  and,  the  periosteum 
covering  the  os  pubis;  and  this  is  to  be  accomplished  without  in- 
juring the  spermatic  vessels,  or  the  tendon  of  the  abdominal  mus- 
cle. 

If  the  spermatic  vessels  are  hurt,  an  inflamed  or  diseased  tes.^ 
ticle  will  be  the  consequence:  if  they  arc  destroyed,  the  testicle 
will  become  useless.  If  the  tendon  of  the  oblique  muscle  be  in- 
jured, either  by  the  iron,  or  by  the  caustic,  terrible  sloughs,  a 
large  ill-conditioned  sore,  and  a  brisk  symptomatic  fever,  must  be 
expected,  which  in  some  habits  must  be  productive  of  considera- 
ble mischief:  and  that  considerable  mischief  was  often  done  by 
these  processes,  may  be  learned  from  the  very  writers  who  des- 
cribe them.*" 

If  the  OS  pubis  be  laid  bare,  whether  by  cautery  or  by  caustic, 
some  of  the  before  mentioned  hazards  must  be  incurred;  if  it  be 
not,  the  intention  will  in  general  be  frustrated;  that  is,  the  intestine 
will  slip  down  behind  the  scar,  and  put  the  patient  under  the  same 

^  Guido,  speaking  of  the  cure  by  caustic,  says,  "  In  quo  summe  cavendum 
"  est,  quod  dominus  sit  de  corrosivo  ;  si  enim  iiidocte  applicatur,  febrim 
"coir.movet,  et  accidentia  mala."  Tl)at  great  pain,  deflation  on  the  he- 
morrhoidal vessels,  and  inflammation  and  swelling  of  the  scrotum,  were  often 
the  consequence  of  these  jtttempts,  may  be  learned  from  the  same  author, 
■who,  speaking  of  the  method  of  applying  the  caustic,  says,  "  Et  ita  continue 
"fiat  quousque  caro  miracis  tota  sit  corrupla,  usque  ad  Didymum,  quod  cog- 
"noscitur  per  inflationem  bursse,  et  tesliculorum."  And  that  the  caustic 
has  gone  deep  enough,  he  gives  the  following  proof:  "  Quod  cognoscetur 
"per  majorem  tumorem  testiculi  et  per  majorem  dolorem  dorsi  et  partium 
"  posteriorum."  Brunus  says,  "Et  cave  summa  diligenlia,  ne  in  hoia  caute- 
"  rizationis  exeat  intestinum,  et  comburatur."  Lanfranc,  speaking  of  the  ill 
effect  of  the  caustic  in  some  habits,  says,  "  Et  sic  multi  spasmantur,  et  spas- 
"  mati  subito  moriuntur,"  Fab.  ab  Aquapendente  says,  "  Qus  tamen  chirur- 
"giae  uti  videtis,  difficiles  admodum  sunt,  et  inter  subtilissimas  haberi  pos- 
"  sunt ;  quo  fit  ut  plerique  patientes  afl^ectus  perpetuo  gestare  quam  his 
"  chirurgis  submittere  se  vellent."  And  in  another  place,  "  Quae  porro  chi- 
"  rurgise  vehementem  dolorem  afferunt  et  satis  difficlles  sunt.  In  short, 
whoever  will  take  the  trouble  of  reading  the  old  writers  on  this  subject,  will, 
even  from  their  own  account,  be  satisfied,  of  the  pain,  hazard,  and  inefficacy 
of  all  these  methods. 

VOL.  I.  3  c 


386  A  TREATISE  ON  RUPTURES. 

necessity  of  wearing  a  bandage,  as  lie  lay  under  before  he  sub- 
mitted to  so  painful  and  so  hazardous  an  experiment. 

If  the  preservation  of  life  was  the  object  of  these  means,  some- 
thing might  be  said  in  their  vindication;  the  anceps  remedium 
must  for  ever  be  preferable  to  desperation:  but  that  is  not  the 
case:  they  are  recommended  to  be  put  in  practice,  when  the  pa- 
tient's life  is  in  no  kind  of  danger,  and  are  designed  merely  to 
save  him  the  trouble  of  wearing  a  truss,  which  purpose  they  can 
seldom  answer;  for  it  is  well  known,  that  after  the  use  of  the 
cautery,  caustic,  and  every  method,  either  proposed  for  a  radical 
cure,  or  used  to  rescue  a  ruptured  patient  from  death,  that  the 
intestine  will  slip  down  behind  the  cicatrix,  and  form  a  new  bu- 
bonocele, which  can  only  be  kept  up  by  a  proper  bandage. 

The  three  other  means  made  use  of  by  the  ancients  toward  ob- 
taining a  radical  cure  were,  the  punctum  aureum,  the  royal  stiteh, 
and  castration. 

The  punctum  aureum  was  performed  as  follows: — The  intes- 
tines being  emptied  by  purging  and  the  hernia  reduced,  an  inci- 
sion was  made  through  the  skin  and  membrana  adiposa,  down  to 
the  spermatic  process.  This  incision  was  to  be  of  such  length, 
as  to  permit  the  operator,  either  with  his  finger  or  with  a  hook,  to 
take  the  said  process,  and  to  pass  a  golden  wire  under  it;  which 
wire  was  to  be  twisted  in  such  a  manner  as  to  prevent  the  intes- 
tine from  slipping  down  again  into  the  hernial  sac,  but  not  so 
tight  as  to  intercept  or  obstruct  the  circulation  of  the  blood  to  the 
testicle.  Some  operators  preferred  a  leaden  wire  to  a  golden  one, 
and  others  a  silken  ligature. 

It  may  possibly-  seem  rather  uncivil  to  say,  that  both  this  and 
the  succeeding  operation  were  directed  and  practised  by  people 
who  were  very  little  acquainted  with  the  true  nature  and  structure 
of  the  parts  they  operated  upon,  or  indeed  of  the  disease  for  which 
they  prescribed  such  operation:  but  had  not  that  been  the  case, 
they  never  could  have  proposed  so  fallacious  and  uncertain  a 
method  of  treating  it;  for  if  the  wire  or  whatever  was  passed 
round  ihe  process  did  not  bind  pretty  tight,  it  would  not  prevent 
a  descent  of  the  gut;  and  the  whole  operation,  though  painfiJ  and 
irksome,  must  become  absoluUiy  uscle'^.s:  if  it  did  bin.^.  -'gi  *,  it 
must  necessupily  retard  hn^  otTs  cuct  ihe  v.ii'cuh  J.;  •'.'^'-d 


A, TREATISE  ON  RUPTURES.  387 

through  the  Spermatic  vessels,  and  produce  a  disease  of  them,  and 
of  the  testicle.^ 

The  royal  stitch  was  performed  ia  this  manner:  the  intestines 
being  emptied,  and  the  portion  which  had  descended  being  re- 
placed, an  incision  was  made  in  such  manner  as  to  lay  bare  the 
spermatic  chord,  aboui  two  inches  in  length  from  the  abdominal 
opening  downward.  When  the  process  was  freed  from  the  cellu- 
lar membrane,  it  was  to  be  held  up  by  an  assistant,  while  the 
surgeon  with  a  needle  and  ligature  made  a  continued  suture,  from 
the  lower  part  of  the  incision  to  the  upper,  in  such  manner  as  to 
unite  the  divided  lips  of  the  wound  again,  comprehending  the  cel- 
lular membrane,  and  thereby  endeavouring  to  straighten  the  pass- 
age, as  they  called  it,  from  the  belly  into  the  scrotum,  without 
injuring  the  spermatic  vessels. 

The  operation  is  described  by  many  of  the  old  writers,'*  with 
some  small  variation  from  each  other,  both  in  the  m^anner  and  in 
the  instruments;  but  all  tending  to  the  same  end,  and  all  proving 
that  their  ideas  of  the  disease,  and  of  the  parts  affected  by  it,  were 
erroneous  and  imperfect. 

The  fatigue  to  the  patient  must  be  greater  in  this  than  in  the 
preceding  operation,  both  on  account  of  the  large  incision,  and  of 
the  suture. 

In  some  habits,  either  of  them  must  be  very  hazardous,  and  in 
the  majority  of  cases,  painful,  troublesome,  and  tedious;  which 
circumstances  might  nevertheless  be  submitted  to,  if  the  cure  was 
certain,  the  contrary  to  which  did  most  frequently  happen,  even 
by  the  confession  of  the  very  writers  who  propose  and  describe 
these  methods,  and  who  universally  order  the  long  wearing  a  truss 
after  such  operations  have  been  submitted  to. 

Some,  who  thought  that  the  stitch  added  unnecessarily  to  the 
pain,  have  directed  the  incision  to  be  made  in  the  same  manner  as 
for  the  suture;  but,  instead  of  sewing  the  lips  together,  have  ad- 
vised that  the  common  membrane   be  dissected  out  pretty  clean, 

g  Whoever  would  know  llie  particular  methods  of  executing  this  opera= 
tion,  may  find  them  in  G  lido,  Parey,  Franco,  Scultetus,  Smaltzius,  Per- 
mannus,  Nuck,  &c. 

!'  Paulus,  Albucasis,  Fab.  ab  Aquapendente.,  Guido,  Rolandus,  Parey,  Ser- 
;ieant  "Wiseman,  &c.  Sec.  &c. 


388  A  TREATISE  ON  RUPTURES. 

and  the  sore  digested  and  incarncd.  This  is  so  like  to  the  opera- 
tion for  the  incarcerated  bubonocele,  both  in  the  manner  of  making 
the  incision  and  in  its  consequence,  as  tending  toward  a  radical 
cure,  that  it  may  be  looked  upon  as  really  the  same  thing;  and 
how  very  fallacious  and  uncertain  that  operation  proves  toward 
answering  this  end  is  too  well  known. 

Both  these,  ihe  royal  stitch  and  the  punctum  aureuni,  proved 
often  destructive  to  the  testicle,  even  in  the  most  judicious  hands; 
and  when  it  got  into  those  of  ignorant  pretenders,  it  proved  most 
frequently  so;  for  not  knowing  how  to  perform  properly  what  they 
had  undertaken,  and  finding  it  much  more  easy,  after  the  incision 
was  made,  to  slip  out  the  testicle,  they  most  commonly  did  so. 

These  are  the  principal  methods  proposed  or  practised  by  our 
forefathers  for  a  radical  cure  of  a  rupture:  among  the  writers  in- 
deed will  be  found  some  trifling  variations  from  each  other  in  the 
execution  of  them,  but  the  intention  and  aim  are  the  same  in  all, 
viz.  to  prevent  a  new  descent  of  either  gut  or  caul,  by  producing 
an  union  of  the  parts,  through  which  they  either  did  or  were  sup- 
posed to  pass.  According  to  the  degree  of  anatomical  knowledge, 
and  humanity  of  the  proposer,  they  will  be  found  to  be  more  or 
less  rational  and  gentle;  but  are  all  of  them  painful,  hazardous, 
and  most  frequently  fallacious,  and  have  therefore  been  totally 
disused  by  all  modern  practitioners,  who  have  either  knowledge, 
compassion,  or  honesty. 

No  disease  has  ever  furnished  such  a  constant  succession  of 
quacks  as  ruptures  have:  they  who  have  had  some  smattering  of 
anatomy  or  surgery,  and  whose  humanity  has  not  been  their  pre- 
vailing quality,  have  adopted  one  of  the  preceding  operations,  or 
something  like  them;  while  they  who  have  had  less  knowledge, 
and  more  timidity,  have  had  recourse  to  the  more  sneaking  knavery 
of  specific  applications. 

The  histories  of  prior  Cabriere,  Bowles,  Sir  Thomas  Renton, 
Dr.  Little  John,  &c.  &c.  &c.  to  be  found  in  Dionis,  Houston,  and 
other  writers,  will  furnish  to  the  reader  an  idea  of  the  practice  and 
performances  of  some  of  those  who  stood  at  the  head  of  those  bold 
promisers:  and  our  present  newspapers  daily  supply  us  wiih  a 
number  of  the  lesser  dealers  in  specific  medicines,  and  new-in- 
vented bandages,  by  which  the  poor  and  eredulous  are  gulled  out 


A  TREATISE  ON  RUPTURES.  389 

of  what  little  money  they  can  spare.  Operative  quackery  is  not 
indeed  so  frequent,  or  so  readily  submitted  to;  but  I  wish  I  could 
say  that  not  more  than  one  life  has  been  destroyed  in  our  own  time, 
by  attempts  to  form  and  support  the  character  of  an  operator  in 
this  disease:  to  this  kind  of  hazard  indeed  the  poor  are  luckily 
not  so  liable,  as  it  can  only  be  worth  the  while  of  these  rupture- 
doctors  to  murder  those  who  have  before-hand  been  simple  enough 
to  pay  them  well  for  it. 

This  is  a  subject  in  which  mankind  are  much  interested,  and 
on  which  a  good  deal  might  he  said;  but  as  an  honest  attempt  to 
save  the  afflicted  from  the  hands  of  those  who  have  no  character 
to  lose,  and  whose  only  point  is  money,  might,  from  one  of  the 
profession,  be  misconstrued  into  malevolence  and  craft,  I  will  not 
enter  into  it,  but  shall  conclude  by  wishing,  that  they  who  have 
capacity  to  judge  of  these  matters  (which  are  as  much  the  objects 
of  common  sense,  as  any  other  kind  of  knowledge)  would  not 
suffer  themselves  to  be  deluded  by  the  impudent  assertions  of  any 
charlatan  whatever,  but  determine  in  this,  as  they  do  in  many 
other  things;  that  is,  by  the  event.  In  short,  if  they  who  have  so 
much  credulity,  as  to  be  inclined  to  believe  and  trust  these  lying 
impostors,  would  only  defer  the  payment  of  them  till  they  had 
completed  their  promises,  the  fallacy  would  soon  be  at  an  end. 


*^*  The  foregoing  Treatise  on  Herni©  must  be  allowed  to  be 
written  with  that  lucid  arrangement  and  perspicuity  which  dis- 
tinguish the  other  productions  from  the  pen  of  Mr.  Pott.  It  is  in- 
deed a  performance  of  extraordinary  merit  for  the  time  in  whick 
it  was  published;  but,  as  science  is  progressive,  it  is  not  to  be 
wondered  at,  if  modern  practitioners  are  enabled  to  discover  in  it 
some  inaccuracies.  It  has  particularly  been  remarked,  that,  in 
page  306,  Mr.  Pott  has  asserted  that  the  external  oblique  muscle  is 
the  only  one  which  has  a  ring  or  opening  in  its  tendinous  fascia: 
that  "  all  descriptions  and  delineations  of  more  openings  than  that 
single  one,  on  each  side,  are  not  representations  of  nature,  but  are 
images  of  luxuriant  fancy,  and  have  no  foundation  in  truth." 
Since  this  was  written,  the  opportunities  of  studying  anatomy 


590  A  TREATISE  ON  RUPTURES. 

have  been  much  facilitated  and  extended,  and  from  more  accurate 
examination  this  description  has  been  found  to  be  not  quite  cor- 
rect. Among  the  laborious  and  accurate  investigators  of  modern 
times,  Mr.  Cooper  holds  a  distinguished  rank.  To  the  subject  of 
Hernias  he  has  paid  particular  attention;  and,  in  the  plates  which 
he  has  given  of  the  parts  concerned,  he  has  plainly  delineated  and 
demonstrated  a  ring  formed  by  the  fascia  of  the  transversalis 
muscle.  This  is  certainly  an  important  fact,  which  ought  to  be 
well  known  and  understood,  as  whoever  proceeds  to  perform  the 
operation  for  an  incarcerated  hernia,  with  a  confidence  that  the 
ring  of  the  external  oblique  can  alone  prevent  the  return  of  the 
contents  of  the  sac,  may  find  himself  much  embarrassed  at  meet- 
ing with  another  stricture,  which  undoubtedly  is  sometimes  caused 
by  the  internal  ring. 

Mr.  Lawrence  also  has  lately  published  an  excellent  practical 
Treatise  on  Hernias,  which  gained  the  Jacksonian  prize  from  the 
Royal  College  of  Surgeons,  and  in  which  this  subject  is  accurately 
investigated. 

I  must  also  observe  on  another  passage,  in  page  362,  in  which 
Mr.  Pott  has  very  properly  deprecated  the  idea  of  tying  the  omen- 
tum by  including  the  whole  of  it  in  a  ligature;  but  though  this  may 
be  productive  of  the  mischiefs  he  has  enumerated,  surely  it  would 
be  right  to  secure  such  vessels  as  are  likely  to  bleed  before  the 
omentum  is  returned  into  the  abdomen.  Those  vessels  in  some 
subjects  are  naturally  large:  by  disease  they  sometimes  become 
larger;  and  cannot,  I  conceive,  be  safely  trusted  without  the 
security  of  ligatures.  If  they  are  tied  singly  and  separately,  the 
bad  consequences  which  Mr.  Pott  has  described  would  be  avoids 
ed.     E. 


391 


THE    FOLLOWING 


OBSERVATIONS  AND  CASES 


HELATITE    TO 


BUPTURES,  6)C. 

Were  written  long  after  the  preceding;  and  in  former  editions  were 
inserted  in  a  different  part  of  the  fVork:  but  being  a  continua- 
tion of  the  same  subject,  they  appear  more  properly  introduced  in 
this  place. 


SECT.  I.         . 

DISEASES  OF  THE  OMENTUM,  PARTICULARLY  OMENTAL  HERNIiE. 

The  general  doctrine  regarding  these  is,  that,  although  they 
are  sometimes  troublesome  from  their  weight  and  size,  yet  the 
omentum  being  insensible,  and  very  little,  if  at  all  necessary  to 
vitality,  they  do  not  call  for  our  immediate  assistance,  and  never 
endanger  the  patient's  life. 

Thai  omental  ruptures  are  not  attended  with  those  immediately 
hazardous  circumstances,  which  necessarily  accompany  intestinal 
ones,  is  a  truth  beyond  all  doubt;  but  that  diseases  of  the  omen- 
tum are  of  little  consequence,  or  that  this  kind  of  rupture  is  so 
harmless,  as  never  to  bring  ihe  life  of  the  patient  into  danger,  and 
to  prove  positivelv  as  well  as  eventually  fatal,  is  a  position  which 
is  bj  no  means  true. 

IiU' stiiial  ruptures  are  primarily  and  originally  hazardous;  and 
this  hazard  arises  as  well  from  the  structure,  as  from  the  func- 


392  OBSERVATIONS  ON  RUPTURES. 

tions  of  the  parts  concerned.  The  tender  membranes  of  the  in- 
testines are  very  little  able  to  bear  any  considerable  degree  of 
inflammation;  and  neither  digestion  of  the  food,  propulsion  of  the 
chyle  into  and  through  the  lacteals,  nor  expulsion  of  the  faeces 
from  the  large  guts,  (offices  absolutely  necessary  to  the  very  exist- 
ence of  the  animal,)  can  be  executed,  while  such  stricture  is  made 
on  any  part  of  the  intestinal  canal  as  either  hinders  its  natural 
motion,  or  renders  its  tube  impervious;  consequently,  whenever 
this  happens,  from  whatever  cause,  the  patient  is  immediately 
disordered,  and  brought  into  a  state  of  hazard. 

The  omentum  is  not  indeed  so  liable  to  injury,  either  from  its 
structure,  or  from  its  office:  the  dislodgement  of  it  from  its  natural 
situation  within  the  belly,  or  its  engagement  in  a  stricture,  seldom 
produces  any  immediate  or  very  pressing  symptoms;  and  therefore 
its  confinement  within  a  hernial  sac  has  seldom  been  regarded  as 
a  matter  of  importance.  Taken  in  a  general  sense,  it  certainly 
is  not.  The  displacement  of  a  mere  portion  of  caul  from  its  na- 
tural situation,  and  the  detention  of  it  in  the  groin  or  scrotum, 
will  not,  in  general,  occasion  any  such  interruption  in  any  of  the 
functions  of  the  animal,  or  so  disorder  its  internal  economy,  as  to 
produce  a  considerable  degree  of  pain  or  hazard:  but  whoever 
from  thence  concludes  that  omental  ruptures  are  absolutely  void 
of  danger,  will  find  himself  much  deceived.  A  more  atlentive 
observation  of  the  disease,  and  of  its  effects,  will  inform  him,  that 
very  considerable  mischief  sometimes  attends  them,  and  that  the 
ill  consequences  of  neglect  or  mismanagement,  though  perhaps 
less  frequent  and  less  rapid,  are  not  less  real. 

The  ills  which  may  attend  omental  herniae  are  of  two  kinds; 
one  of  which  is  primary  or  original,  proceeds  from  the  part  which 
first  formed  the  rupture,  and  is  confined  to  it  independent  of  any 
other;  the  other  is  secondary,  or  an  accidental  consequence,  flow- 
ing indeed  from  the  same  original  malady,  but  afleciing  other 
parts  also. 

The  omentum  is  liable  to  inflammation,  suppuration,  gangrene, 
mortification,  and  scirrhus,  while  in  its  natural  situation  within 
the  cavity  of  the  belly;  and  each  of  these  slates  is  oflen  the  real, 
though  most  commonly  unsuspected,  cause  of  very  alarming 
symptoms,  and  not  infrequently  of  death. 


OBSERVATIONS  ON  RUPTURES.  393 

it  is  not  only  liable  to  the  same  morbid  alterations,  when  thrust 
forth  from  the  cavity  into  a  hernial  sac,  but  the  neglect  or  mis- 
management of  it,  when  there,  is  productive  of  these  and  other 
evils,  which,  for  want  of  a  proper  attention,  have  either  been  to- 
tally overlooked,  or  set  to  the  account  of  other  causes.  Violent 
or  continued  pressure  on  it  has  produced  inflammation  with  all  its 
consequences;  has  brought  on  fever  of  a  very  bad  kind,  suppura- 
tion, slough,  and  sphacelus;  long  confinement  of  it  within  a  her- 
nial sac  has  occasioned  such  other  alteration  in  its  form  and  tex- 
ture as  to  render  it  truly  a  diseased  body,  and  to  produce  many 
inconveniences  from  such  its  morbid  state;  and  an  undue  or  in- 
terrupted circulation  through  it,  by  means  of  stricture,  occasions, 
sometimes,  such  a  collection  of  extravasated  fluid  in  the  sac,  as 
to  render  it  a  necessary  object  of  a  surgeon's  attention;  not  to 
mention  that  the  dragging  down  a  larger  portion  of  the  caul  into 
the  scrotum,  proves  sometimes  more  than  merely  disagreeable,  by 
reason  of  its  connexion  with  the  abdominal  viscera. 

These  are  ills  which  arise  from  omental  ruptures  primarily, 
and  are  dependent  upon  the  nature  of  the  disease,  considered  ab- 
stractedly, without  any  view  to  or  connexion  with  any  other. 
But  there  is  another,  which,  although  it  may  be  called  secondary, 
or  be  considered  as  a  consequence,  is  both  frequent  and  ha- 
zardous. 

When  a  portion  of  the  peritoneum,  forming  a  hernial  sac,  has 
been  thrust  quite  down  into  the  scrotum,  I  believe  I  may  venture 
to  affirm,  (notwithstanding  what  may  have  been  said  to  the  con- 
trary,), that  it  seldom  or  never  returns  back  into  the  abdomen 
again,  but  becomes  immediately,  and  wholly,  connected  with  the 
cellular  membrane  investing  the  spermatic  vessels;  so  that  who- 
ever has  once  had  such  sac  so  protruded  can  never  have  any  se- 
curity against  the  disease  called  a  rupture,  but  what  is  derived 
from  such  means  as  may  render  the  entrance  into  that  bag  too 
small  to  permit  any  thing  to  pass  from  one  cavity  into  the  other. 
Upon  this  principle,  and  on  this  only,  stands  the  utility,  and  in- 
deed the  necessity,  of  trusses  and  such  kinds  of  bandages.  By 
these,  in  infants,  and  in  young  subjects,  such  a  coarctation  or 
lessening  of  the  entrance  into  the  sac  is  produced,  that  a  firm  and 
permanent  cure  is  often  obtained;  but  in  the  luajority  of  adults, 

VOL.  I.  3  p 


o'JL  OBSERVATIONS    ON  RUPTURES, 

antl  ill  all  people  far  advanced  in  life,  such  effect  is  not  to  be  ex- 
pected. It  does  indeed  happen  to  some  few,  but  it  is  to  be  re- 
garded as  an  accidental  benefit;  and  the  bandage  being  the  only 
means  whereby  a  descent  can  b«  prevented,  it  ought  to  be  con- 
stantly and  uniemitllngly  worn. 

Whoever  has  a  just  idea  of  an  hernial  sac  must  be  convinced, 
that  while  a  body,  or  substance  of  any  kind,  possesses  that  part  of 
it  whicii  communicates  immediately  with  tlie  belly,  such  passage 
can  never  be  closed:  and,  consequently,  that  the  one  point,  in  which 
even  the  palliative  cure  of  a  rupture  consists,  can  never  be  acconi- 
pHshed. 

A  portion  of  omentum,  although  it  be  compressible,  soft,  and 
slippery,  will,  while  it  remains  in  such  passage,  keep  it  as  con- 
stantly and  as  certainly  open,  as  any  other  body  whatever;  and  from 
the  very  circumstances  of  its  being  soft,  slippery,  and  compressi- 
ble, will  still  more  easily  let  any  other  body  pass  by  it:  a  portion 
of  the  intestinal  canal  is  frequently  pressed  against  the  mouth  of 
this  sac,  and  that  with  considerable  force.  The  orifice  being 
open,  and  the  omentum  afibrding  but  little  resistance,  the  said 
portion  is  often  pushed  into  the  bag;  and  by  this  means  a  new,  and 
still  more  interesting  and  hazardous  complaint,  is  added  to  the  old 
one. 

This  happens  much  more  frequently  than  it  is  supposed  to  do-; 
and  is,  in  the  nature  of  things,  so  probable,  that  no  person  who 
has  an  omental  rupture  can,  for  any  the  shortest  space  of  time, 
be  said  to  be  secure  against  the  descent  of  a  portion  of  intestine; 
and  consequently  is  always  liable  to  every  kind  and  degree  o-f 
hazard  attending  an  intestinal  one. 


CASE  I. 

A  GENTLEMAN,  about  forty-thrcc  years  old,  had,  for  some  time, 
been  subject  to  a  rupture  of  the  omental  kind,  which  came  down 
when  he  was  in  an  erect  posture,  and  went  up  with  great  ease 
when  he  lay  supine. 

I  reduced  it,  and  put  on  him  a  truss,  which  answered  the  pur- 


OBSERVATIONS  ON  RUPTURES.  395 

pose  very  well,  by  keeping  the  rupture  up  all  the  while  it  was 
worn:  but  the  patient,  disliking  the  necessary  degree  of  pressure, 
and  finding  very  little  inconvenience  from  his  disease,  (it  being 
merely  a  piece  of  caul,)  laid  aside  the  use  of  his  bandage,  and 
suffered  his  rupture  io  take  its  own  course. 

Being  obliged  to  take  a  long  journey  on  horseback,  and  being 
apprehensive  that  his  complaint  might,  by  exercise  in  hot  weather, 
prove  troublesome,  he  had  a  mind  to  put  his  truss  on  again,  not 
doubting  but  that  he  could  replace  his  rupture  as  easily  as  he  had 
been  accustomed  to  do:  be  tried  several  limes,  but  could  not  ac- 
complish it.  He  came  to  me;  I  tried,  and  was  foiled.  I  repeated 
the  attempt  again  and  again,  but  to  no  purpose,  still  being  clear 
that  the  disease  consisted  only  of  a  portion  of  omentum,  and  that 
not  large. 

From  me  he  went  to  one  of  the  advertisers;  who  having,  for  a 
day  or  two,  amused  him  with  anointing  his  groin,  put  on  him  a 
bandage  with  a  large,  hard  bolster;  which  being  buckled  very 
tight,  he  was  permitted  to  begin  his  journey,  and  was  told  that, 
long  before  he  returned,  the  portion  of  caul  would  be  shrunk  to 
nothing,  and  his  disease  thereby  cured.  He  set  out,  and  got  about 
twenty  miles,  when  he  found  himself  so  ill,  and  in  so  much  pain, 
that  he  determined  to  come  back  to  London;  which  he  accom- 
plished with  great  difficulty, 

I  found  him  in  extreme  pain  all  over  his  belly,  which  would 
hardly  bear  being  touched;  he  was  incapable  not  only  of  sitting  or 
standing  upright,  but  even  of  lying  straight  upon  his  back;  he 
could  hardly  bear  the  weight  of  the  bed-clothes;  and  the  most 
gentle  pressure,  toward  the  bottomof  his  belly,  and  his  groin,  was 
intolerable.  The  scrotum,  and  spermatic  process,  on  the  ruptured 
side,  were  swollen,  tense,  and  inflamed;  his  skin  was  hot  and  dry, 
his  pulse  hard  and  frequent,  and  he  had  such  a  degree  of  restless- 
ness, that,  although  motion  was  very  painful  to  him,  yet  he  could 
not  lie  still  for  two  minutes. 

Notwithstanding  the  many  opportunities  which,  before  this 
accident,  I  had  had  of  knowing  the  true  nature  of  his  rupture,  and 
that  I  was  perfectly  convinced  that  it  had  always  been  omental 
merely,  yet  from  his  acute  pain,  from  the  enlarged  and  inflamed 
state  of  the  process,  and  from  the  nature  and  rapidity  of  his  symp» 


396  OBSERVATIONS  ON  RUPTURIiS. 

toms,  I  was  much  inclined  to  believe,  that  a  portion  of  intestine 
had  some  share  in  the  present  mischief;  but  the  patient,  who  was 
a  very  intelligent  man,  insisted  on  it  that  it  had  not,  and  that  all 
his  present  malady  was  caused  by  the  pressure  of  the  truss  on  the 
omentum. 

I  took  away  a  considerable  quantity  of  blood,  and,  notwith- 
standing the  patient's  opinion,  directed  a  solution  of  the  sal  rupell. 
in  infus.  sennas  to  be  taken  immediately,  and  a  purging  clyster  to  be 
thrown  up  as  soon  as  it  could  be  got  ready;  for  the  parts  were  m 
such  a  state,  that,  had  there  been  more  convincing  marks  of  intes- 
tinal stricture,  reduction  by  the  hand  was  at  that  time  impractica- 
ble, and  unfit  to  be  attempted.  I  saw  him  in  about  six  or  eight 
hours.  The  discharge  per  anum  had  been  such  as  to  put  an  end 
to  all  suspicion  of  stricture  on  any  part  of  the  intestinal  tube,  but  his 
inflammatory  symptoms  were  not  at  all  lessened.  I  took  away 
more  blood,  and  would  fain  have  put  him  into  a  semicupium,  but 
the  dread  of  motion  prevented  him  from  complying  with  it.  His 
pain  was  excessive;  and  as  he  had  now  lost  a  very  considerable 
quantity  of  blood,  and  had  had  a  very  free  discharge  by  stool,  I 
threw  up  a  clyster  of  warm  water,  oil,  and  laudanum,  and  gave 
him  two  grains  of  extract,  thebaic,  by  the  mouth.  He  passed  s« 
bad  a  night,  that  he  was  glad,  early  in  the  morning,  to  comply  with 
the  use  of  the  bathing  tub,  by  the  repeated  use  of  which,  and 
taking  care  to  keep  the  body  open,  by  lenient,  oily  remedies,  he, 
at  the  end  of  four  days,  got  to  be  easy. 

Fomentation  and  poultice  reduced  the  tumefaction  in  the  groin 
and  scrotum;  and  when  they  were  removed,  the  rupture  appeared 
to  be  nearly  in  the  same  state  as  before  the  accident,  oily  a  little 
larger. 

Two  years  after  this  he  died,  and  was  opened;  his  rupture  was 
found  to  be  merely  omental,  and  the  portion  of  caul  which  formed 
it  was,  in  its  infcTior  part,  adherent  to  the  hernial  sac  in  two 
places. 


OBSERVATIONS    ON   RUPTURES.  39') 


CASE  II. 


A  YOUNG  man,  who  worked  as  a  journeyman  with  a  silversmith 
in  Foster-lane,  came  to  me  three  or  four  different  times,  on  ac- 
count of  a  rupture,  which  appeared  to  have  every  mark  of  being 
merely  omental. 

It  was  large,  and  had,  as  he  said,  been  for  some  years  easily  re- 
ducible; but  it  was  not  at  all  so  at  his  last  visit  to  me.  By  a  late 
increase  of  size  and  weight,  it  was  become  very  troublesome,  as 
well  as  very  visible.  Finding  reduction  impracticable,  I  recom- 
mended to  him  the  use  of  a  suspensory  bandage,  and  gave  him  di- 
rections for  his  general  conduct. 

At  the  distance  of  about  six  months  from  his  last  visit,  I  was 
sent  for  to  St.  Bartholomew's  hospital  in  a  hurry,  to  a  person 
supposed  to  labour  under  a  hernia  with  stricture. 

I  found  a  man  who  was  only  not  dead;  he  had  a  dying  coun- 
tenance, a  faltering  pulse,  a  constant  hiccough,  and  cold  extre- 
mities. 

As  it  did  not  appear  to  me  that  it  was  possible  for  me  to  do  him 
any  service,  I  was  going  away,  but  was  called  back  at  the  pa- 
tient's particular  request.  He  made  himsejf  known  to  me  to  be 
the  person  I  have  just  mentioned;  and  a  friend  who  was  with 
him,  gave  me  the  following  account: — 

That  a  few  days  before,  having  an  intention  to  marry,  and  be- 
lieving that  his  rupture  would  be  prejudicial  to  him,  he  had  ap- 
plied to  somebody  who  had  been  recommended  to  him  for  relief; 
that  the  person  to  whom  he  applied,  having  received  from  him 
such  gratuity  as  he  could  afford  at  that  time,  in  part  of  payment, 
had  promised  to  cure  him  within  a  month;  that  he  anointed  him 
for  two  or  three  days  with  an  ointment,  and  then  put  on  him  a 
very  strict  bandage;  that  he  was  ordered  to  wear  this  bandage 
constantly,  day  and  night;  that  when  he  had  worn  it  three  days. 
not  being  able  longer  to  endure  the  pain  it  caused,  he  took  it  off, 
and  went  to  his  surgeon,  who  seemed  to  be  surprized,  and  bad 
him  go  home,  apply  to  his  groin  and  scrotum  a  poultice  made  of 
boiled  turnips  and  hog's-lard,  and  come  to  him  again  the  next 


398  OBSERVATIONS  ON  RUPTURES. 

day;  tliat  the  inflammation  and  swelling  increasing,  he  was  pre- 
vented from  fullilling  the  last  injunction,  and  therefore  sent  for  his 
operator,  who  came  to  him,  examined  the  parts,  said  he  had  got 
the  pox,  and  refused  to  do  any  thing  more  for  him  without  the  de- 
posit of  another  five  guineas;  and  that  not  being  able  to  comply 
with  this  demand,  his  friends  had  brought  him  to  the  hospital. 

The  scrotum  had  been  of  considerable  size,  but  was  now  sub- 
sided; it  had  been  very  painful,  but  was  now  easy;  it  was  in  many 
places  livid;  and,  upon  handling,  the  fingers  perceived  that  alarm- 
ing crepitus,  which  infallibly  denotes  putrid  air  from  gangrenous 
membranes. 

When  I  saw  him  in  health,  I  was  perfectly  satisfied,  that  his 
rupture  was  merely  omental;  I  was  as  much  satisfied,  that  his 
present  state  wtis  owing  to  his  bandage;  but  nevertheless  I  cannot 
but  say,  that  I  suspected  a  piece  of  intestine  to  have  slipped 
down,  and  to  have  occasioned  this  fatality  by  being  pressed  on. 

I  inquired  into  his  discharge  by  stool,  and  was  told,  that  he  had 
a  large  one  within  the  last  two  days,  but  having  often  experienced 
how  liable  people  are  to  deception  in  these  cases,  I  did  not  give 
entire  credit  to  the  account. 

That  eyening  he  died,  and  next  morning  he  was  opened. 

The  scrotum  and  hernial  sac  were  completely  mortified,  and 
within  the  latter  was  a  small  quantity  of  a  most  exceedingly  of- 
fensive sanies,  together  with  a  large  piece  of  sphacelated  omen- 
tum only.  The  whole  intestinal  tube  was  within  the  belly  per- 
fectly sound,  and  in  good  order;  but  the  omentum  within  that 
cavity  had  partaken  considerably  of  the  mischief  done  to  that 
part  of  it  which  was  in  the  hernial  sac.  and  was  gangrenous 
throughout. 


CASE  III. 

I  WAS  desired  to  visit  a  gentleman  at  Hackney,  who  had  for 
some  years  been  afflicted  with  a  rupture,  which  at  different  times 
had  been  examined  by  Mr.  Sainthill,  Mr.  Samuel  Sharpe,  and 
others;  and  had,  by  every  body,  been  deemed  to  be  merely  omen- 
tal.    For  some  years  it  had  been  kept  up  by  means  of  a  steel 


OBSERVATIONS  ON  KUPTURF.S.  399 

truss;  but,  a  few  months  before  I  suw  bim  he  had  laid  aside  his 
truss,  and  had  put  on  a  dimity  bandage,  ^vilh  a  Large  bolster, 
which  he  had  worn  very  tig'ally  buckled.  How  he  had  managed 
himself  in  other  respccls,  I  know  not;  but  I  found  him  with 
his  groin  and  scrotum  much  swollen,  and  very  painful  to  the 
touch;  he  was  hot  and  feverish,  and  had  been  two  days  without  a 
stool.  The  state  of  the  parts  was  such,  that  an  immediate  attempt 
to  reduce  the  rupture  by  the  hand  was  impracticable,  at  least 
could  not  have  been  aitended  with  any  probability  of  success.  He 
was  immediately  let  blood,  had  a  clyster,  and  an  aperient  draught. 
Next  day  1  found  him  worse,  in  more  pain,  with  more  inflamma- 
tion, and  a  greater  degree  of  tumefaction,  and  had  not  yet  had  a 
stool.  I  was  obliged  to  depend  on  the  patient's  own  account  of 
his  case  previous  to  this  attack.  He  insisted  on  it,  that  his  rup- 
ture had  neve;r  been  intestinal,  and  that  every  body  who  had  seen 
it  had  given  him  that  assurance.  This  I  could  not  contradict, 
but  was,  at  the  same  time,  much  inclined  to  believe,  that  a  por- 
tion of  intestine  was  down  now.  The  cataplasm  was  applied 
over  the  whole  scrotum  and  groin,  a  stimulating  clyster  again 
thrown  up,  and  a  purging  mixture  ordered  to  be  taken,  cochleatim, 
every  tWo  hours,  until  he  should  have  stools,  but  all  to  no  pur- 
pose. 

On  the  third  day  he  was  worse  in  every  respect;  his  belly  ex- 
ceedingly tense,  his  pain  great,  his  restlessness  fatiguing,  arid  he 
felt  not  the  least  tendency  towards  a  discharge  per  anum. 

I  proposed  the  operation,  but  the  patient  and  his  friends  ob- 
jected. A  clyster,  of  an  infusion  of  tobacco,  was  administered. 
This  produced  such  sickness  and  languor,  with  cold  sweats,  &c.  as 
alarmed  every  body,  but  produced  no  stool. 

Late  in  the  evening,  he  submitted  to  the  operation.  The  parts 
were  now  so  altered,  that  I  guarded  myself  with  a  most  doubt- 
ful prognostic.  I  made  an  incision  from  the  groin  to  the  bottom 
of  the  scrotum:  the  skin,  dartos,  and  hernial  sac,  were  all  gan- 
grenous; and  from  the  cavity  of  the  sac  I  let  out  a  considerable 
quantity  of  a  most  offensive  sanies,  and  with  it  a  large,  putrid 
slough,  which  appeared  to  have  been  a  part  of  the  omentum.  I 
examined  the  opening  in  the  abdominal  muscle,  and  was  satisfied 
that  it  was  in  a  natural  state,  and  (hat  nothing  from  the  abdomen 


400  OBSERVATIONS  ON  RUPTURES. 

was  engaged  in  it.  On  which  account,  I  did  not  meddle  with  it, 
but  having  dressed  the  wound  superficially,  put  on  his  poultice 
again.  Dr.  de  la  Cour  was  present  at  the  operation,  and  directed 
for  the  patient.  Another  day  passed  without  stool,  and  this  I 
thought  must  have  been  his  last  day;  but  on  the  fifth  he  had  a 
most  plentiful  discharge,  and  was  thereby  relieved  from  the  ten- 
sion of  his  belly,  and  his  most  troublesome  symptoms. 

The  sore  was  a  long  time  crude  and  unkindly,  but  by  means  of 
the  bark,  and  proper  diet,  all  difficulties  were  surmounted,  and 
the  patient  got  well. 

Had  a  piece  of  intestine  been  in  the  sac,  it  must,  I  think,  have 
necessarily  partaken  of  the  state  in  which  both  it  and  the  omen- 
tum were;  and  although  the  patient  might  possibly  have  survived, 
yet  a  discharge  of  fsBces  through  the  wound  must,  at  least  for  a 
time,  have  been  the  consequence;  but  here  was  nothing  of  that 
kind,  nor  any  reason,  after  the  constipation  was  removed,  to  sup- 
pose that  the  intestine  had  ever  sustained  any  injury,  or  had  any 
share  in  the  complaint. 


CASE  IV. 

A  BiAN,  about  fifty-five  years  old,  asked  my  opinion  concerning 
a  hard  swelling,  which  he  had  on  each  side,  both  in  the  groin  and 
scrotum.  '' 

To  the  eye  they  appeared  like  omental  hernias;  but  upon  ex- 
amination, they  were  not  only  unequal  in  their  surface,  but  craggy„ 
and  incompressibly  hard. 

The  patient  said,  that  at  the  time  of  handling  them  they  gave 
him  very  little  uneasiness,  but  that  such  handling  always  made 
ihem  painful  for  some  time  after:  that  he  was,  at  times,  attacked 
with  acute  pain  darting  through  his  belly,  up  into  his  loins;  and 
that  such  attack  was  frequently  attended  with  a  nausea,  and  an 
Inclination  to  vomit;  that  he  had  been  subject  to  a  painful  colic, 
attended  generally  with  constipation  of  belly;  that  an  erect  pos- 
ture, if  continued  for  any  length  of  time,  was  very  irksome;  that 
these  swellings  were  for  several  years  soft,  and  easily  returnable 
into  the  belly;  that  while  they  were  so,  he  had,  by  the  advice  of 


OBSERVATIONS  ON  RUPTURES.    '  401 

Mr.  Samuel  Sharpe,  worn  a  steel  truss;  but  that  being  engaged  iu 
a  bustling  active  kind  of  life,  and  the  truss  not  always  doing  its 
duty,  he  had  left  it  off  for  some  years.  That  for  the  last  two 
years  he  had  never  been  able  to  return  either  of  them,  since  which 
they  had  altered  very  much;  that  in  their  present  state  he  had 
consulted  several  of  the  profession,  and  some  quacks;  that  by  some 
they  had  been  deemed  scirrhous  testicles;  by  others,  scirrhi  of  the 
spermatic  processes;  that  he  had  gone  through  a  course  of  mer- 
curial inunction;  had  taken  freely  of  the  solution  of  sublimate  cu. 
de  coot.  rad.  sarsaparillae,  and  had  (in  his  own  phrase)  swallowed 
a  wheel-barrow-full  of  cicuta;  that  he  had  been  promised  a  cure 
by  having  them  laid  open,  to  which  he  had  submitted,  had  not  the 
operator  been  too  lavish  in  his  promises,  and  too  exorbitant  in  his 
demands;  and  that  frequent  attempts  had  been  made  to  soften 
them  by  fomentation,  poultice,  &c.  but  all  to  no  purpose. 

He  had  a  sallow  complexion,  a  languid  fatigued  look,  a  weak 
irregular  pulse,  too  much  heat  and  thirst,  and  too  little  urine:  upon 
the  whole,  he  seemed  a  very  improper  subject  for  any  chirurgic 
treatment,  if  any  could  have  been  rationally  proposed;  but  as  it 
did  not  appear  to  me  that  any  thing  of  that  kind  could  be  done  for 
him,  I  advised  him  to  keep  his  scrotum  suspended,  and  to  consult 
a  physician  on  account  of  his  general  slate. 

Not  long  after,  his  legs  swelled,  he  lost  his  appetite,  and  his 
urinary  secretion  almost  totally  ceased.  The  consequence  of 
which  was,  a  general  anasarca,  and  death. 

In  each  groin,  and  on  each  side  in  the  scrotum,  was  a  hernial 
sac,  bearing  all  the  marks  of  antiquity:  in  eajch  of  these  was  a 
hard,  knotty,  irregular  kind  of  body,  whose  surface  was  covered 
with  varicous  vessels. 

These  bodies  passed  from  the  cavity  of  the  belly,  through  the 
opening  in  the  abdominal  muscle,  were  continuations  from  tlse 
omentum,  and  were  truly  cancerous. 


CASE  V. 

That  the  residence  of  a  portion  of  omentum  in  an  open  hernial 
sac,  must  render  the  patient  constantly  liable  to  the  descent  ©f  a 
VOL.  I.  .S  E 


402  OBSERVATIONS  ON  RUPTURES, 

portion  of"  intestine,  is  .so  self-evident,  that  it  cannot  admit  the' 
smallest  doubt;  but  the  following  case  being  rather  remarkable  I 
have  inserted  it. 

A  drunken  idle  fellow,  who  lived  in  the  neighbourhood  of  St. 
BarthoJome^v''s,  used  to  come  frequently  to  the  surgery  for  pled- 
gets for  broken  heads,  &c.  He  had  also  a  small  omental  hernia, 
as  fairly  and  decisively  characterised  as  possible.  Myself,  and 
all  the  surgeons,  had  at  different  limes  replaced  it  for  him,  and  the 
hospital  hadionce  or  twice  given  him  a  truss;  but,  being  much 
oftencr  drnnk  than  sober,  he  seldom  wore  it  at  all,  and  when  he 
did,  it  was  scldnm  in  the  right  place. 

One  day  while  i  was  at  the  hospital,  he  was  brought  in  with  an 
immense  swelling  of  the  scrotum,  and  all  the  symptoms  of  a  her- 
nia with  stric'ure,  and  those  so  far  advanced,  that  he  had  no 
chance  but  from  the  operation,  which  I  therefore  performed  im- 
mediately. 

In  the  sac  was  a  considerable*  portion  of  the  ileum,  and  a  large 
piece  of  the  colon,  with  the  appendicula  vermiformis,  together 
with  the  small  piece  of  omentum,  which  had  constituted  the  ori- 
ginal rupture.     The  parts  were  mortified,  and  the  man  died. 

Unless  it  can  be  supposed,  that  so  large  a  quantity  of  intestine 
could,  by  every  body,  be  mistaken  for  a  small  one  of  omentum 
only,  it  must  be  clear  that  the  residence  of  that  small  piece  of 
omentum,  gave  the  opportunity  for  the  formation  of  the  intestinal 
hernia,  and  cost  the  poor  man  his  life;  more  especially  if  it  be 
noted,  that  the  increase  of  tumefaction  and  attack  of  bad  symp- 
toms were  the  immediate  consequence  of  an  exertion  of  strength. 


CASE  VI. 

While  I  was  correcting  these  papers  for  the  press,  I  was  de- 
sired to  go  down  to  St.  Katharine's  to  see  a  patient,  who  was  sup- 
posed to  be  afflicted  with  an  incarcerated  hernia. 

I  found  a  man  between  sixty  and  seventy,  whose  scrotum  was 
large  and  full,  and,  as  I  thought,  contained  both  omentum  and  in- 
testine. 

Tt  was  the  third  day  since  he  had  had  a  stool,  although  gentle 


OBSERVATIONS  ON  RUPTURE$>  403 

cathartics  had  been  given  eacli  day.  His  pulse  waft  rather  full, 
but  otherwise  not  much  amiss;  he  had  now  and  then  an  inclina- 
tion to  vomit,  and  his  belly  was  very  tense;  but,  on  the  other  hand, 
he  had  neither  the  sensation  of  general  or  local  pain,  either  upon 
being  examined,  or  put  into  motion,  which  persons  labouring  under 
a  stricture  most  commonly  have;  neither  had  the  spermatic  pro- 
cess the  feel  which  it  usually  has  in  such  cases. 

I  could  not  say  that  I  thought  him  in  immediate  hazard,  al- 
though the  irreducibility  of  his  rupture,  and  the  length  of  time 
which  bad  passed  since  he  had  a  stool,  were  certainly  unfavour- 
able circumstances.  I  directed  a  tobacco  clyster  to  be  given  im- 
mediately, and  five  grains  of  extractum  calharticum  to  be  taken, 
alternis  horis,  until  he  should  have  a  stool.  The  clyster  was  ad- 
ministered and  repeated,  and  the  pills  were  taken,  and  I  visited 
the  patient  early  the  next  morning. 

He  had  not  had  any  discharge  per  anum,  his  belly  was  become 
much  more  tense,  and  I  thought  him  upon  the  whole  so  much 
worse,  that  I  proposed  the  operation,  and  the  patient  submitted 
to  it. 

In  the  hernial  sac  was  a  large  piece  of  omentum,  or  rather  of 
what  had  been  omentum,  but  which  was  now  hardened  into  a 
large  flat  cake,  as  incompressible  as  cold  bees'-wax,  and  about  the 
size  of  a  large  mangoe:  it  distended  all  the  upper  part  of  the  sac, 
and  was  adherent  to  the  lower  part  of  it.  Behind  this  large  body 
lay  a  portion  of  the  intestinum  ileum;  and,  below  this,  that  part  of 
the  colon  which  is  annexed  to  it;  the  colon  was  considerably  dis- 
tended with  flatus;  and  the  ileum  was  so  wedged  in  and  pressed, 
by  the  altered  omentum,  that  nothing  could  possibly  pass  through 
it.  When  the  portion  of  omentum  was  removed,  the  tendon  made 
so  little  stricture  on  the  gut,  that,  had  it  not  been  for  the  great  dis- 
tention  of  the  colon,  it  might  have  been  returned  into  the  belly 
without  division. 

In  short  the  constipation  of  belly,  and  mischief  proceeding  from 
thence,  seemed  to  arise  entirely  from  compression  made  by  the 
hardened  omentum,  and  not  from  a  stricture. 


404  OBSERVATIONS  ON  RUPTURES. 


In  my  general  treatise  on  ruptures,  I  have  ventured  to  dlssenfc 
from  the  commonly  received  doctrine  concerning  the  propriety  of 
tying  the  omentum  previous  to  its  extirpation,  when  it  may  be 
found  necessary  to  remove  a  part  of  it;  and  have  said,  that  I 
thought  it  not  only  unnecessary,  but  pernicious. 

Perhaps  I  may  have  conceived  an  unreasonable  prejudice 
against  this  practice,  and  it  maj  not  appear  to  others  so  ha- 
zardous, or  so  improper,  as  it  does  to  me;  perhaps  the  cases  which 
follow,  and  which  are  some  of  those  that  have  furnished  me  with 
my  objections,  may  not  be  thought  cases  in  point;  and  the  mis- 
carriages in  them  may  be  thought  to  be  deducible  from  other 
causes:  all  I  can  say  is,  that  it  appeared  to  me,  that  the  patients 
suffered  principally,  if  not  merely,  from  this  cause;  and  that  as  I 
am  by  repeated  experience  convinced,  that  a  portion  of  the  omen- 
tum, however  large,  may  be  extirpated  with  perfect  safely,  with- 
out being  previously  tied,  I  shall  never  practise  or  advise  the 
ligaiare. 


CASE  VIl, 

A  MAN,  about  thirty  years  old,  was  taken  into  St.  Bartholo- 
mew's hospital  for  a  considerable  swelling  of  the  groin  or  scrotum. 

The  account  he  gave  of  himself  was  as  follows:  that  he  had  for 
several  years  a  rupture,  which  many  surgeons,  who  had  seen  it, 
had  deemed  to  be  merely  omental;  that  he  had  formerly  had  a 
truss,  but  whether  from  its  being  ill  made,  or  from  his  injudicious 
manner  of  wearing  it,  it  had  never  kept  his  rupture  properly  up, 
and  he  had  long  disused  it;  and  that  the  day  before  he  was  brought 
into  the  hospital,  a  horse  had  kicked  him  in  the  groin,  and  brought 
on  that  increase  of  pain  and  swelling  of  which  he  now  com- 
plained. 

It  was  Mr.  Nourse's  week  for  accidents,  and  he  consequently 
took  the  care  of  him.  He  was  let  blood,  had  a  clyster,  and  a 
poultice  was  applied. 

The  next  day  the  swelling  was  the  same,  and  the  man  had  not 


OBSERVATIONS  ON  RUPTURES.  406 

Jiad  any  stool.  A  purge  was  administered,  which  he  ejected  by 
vonfiil;  and  another  clyster  was  injected  in  the  evening.  On  the 
third  day,  finding  that  nothing  had  passed,  Mr.  Nourse  suspected 
that  the  intestine  was  concerned:  he  bled  the  man  again  largely, 
and  ordered  two  spoonfuls  of  a  purging  mixture  to  be  given  every 
two  hours,' until  he  should  have  stools.  That  evening  he  vomited 
two  or  three  times;  and  next  morning,  Toeing  still  without  a  stool, 
Mr.  Nourse  determined  upon  the  operation. 

The  hernial  sac  was  sound,  thick,  and  tough,  and  contained  a 
portion  of  omentum,  and  some  bloody  water.  Mr.  Nourse  and 
myself  both  examined  the  omentum  carefully,  upon  a  supposition 
that  we  should  find  some  intestine  within  it.  It  was  perfectly 
sound,  but  its  vessels  were  considerably  dilated:  there  was  no  in- 
testine, nor  did  the  tendon  bind  upon  the  omentum.  As  there 
was  no  gut  down,  and  as  the  portion  of  caul  v/as  now  too  large 
to  repass  the  ring,  Mr.  Nourse  made  a  strict  ligature  on  it,  just 
On  this  side,  and  cut  it  off. 

Soon  after  the  operation,  the  man  had  stools;  but  during  that 
night  got  little  or  no  sleep,  and  complained  of  much  pain.  The 
next  day  he  was  worse,  was  feverish,  complained  of  great  pain 
about  his  navel,  and  that  he  could  not  sit  or  stand  upright,  but 
had  two  loose  stools. 

On  the  third  day  he  was  still  worse;  that  is,  had  more  fever, 
complained  that  his  pain  in  his  belly  was  excessive,  and  could 
keep  nothing  on  his  stomach.  On  the  fourth  day,  toward  even- 
ing, his  pain  suddenly  left  him,  and  early  in  the  morning  he  died. 

Mr.  Nourse,  who  was  still  apprehensive  that  the  intestinal  ca- 
nal was  some  way  or  other  concerned  in  the  mischief,  desired 
me  to  open  the  body. 

The  abdominal  tendon  was  sound  and  unhurt,  nor  was  there 
any  such  appearance  about  the  wound  as  always  accompanies 
mischief  proceeding  from  thence:  the  intestiries  were  perfectly 
free  from  blemish,  inflammation,  or  obstruction,  nor  was  there 
any  appearance  of  disease  of  any  kind  on  or  about  any  of  the  vis- 
cera, except  the  omentum,  w^hich  was  gangrenous  through  its 
whole  extent. 

What  share  the  inflammation  of  the  omentum  might  have  in 
prefienting  a  free  passage  through  the  intestines  I  know  not,  nor 


406  OBSERVATIONS  ON  RUPTURES. 

to  what  other  cause  such  obstruction  might  possibly  be  owing; 
but  that  the  omentum  was  sound,  at  the  time  of  the  operation, 
and  gangrenous  when  the  patient  died,  is  beyond  all  doubt. 


CASE  VIIL 

A  MAN,  about  forty  years  old,  who  had  for  several  years  been 
afflicted  with  a  rupture  which  had  always  been  deemed  to  be 
merely  omental,  was  brought  into  St.  Bartholoinew's  hospital  la- 
bouring under  all  the  symptoms  of  an  intestinal  hernia,  with  stric- 
ture; and  those  so  pressing,  that  the  operation  immediately  per- 
formed was  his  only  chance. 

Upon  dividing  the  sac,  a  large  piece  of  omentum  (which  was 
considerably  thickened  in  its  texture,  and  whose  vessels  were  con- 
siderably distended)  presented  itself.  This  was  carefully  ex- 
panded, as  far  as  it  would  admit,  and  laid  first  on  one  side,  and 
then  on  the  other,  but  no  other  body  discovered.  The  incision 
being  continued  higher  up,  in  order  to  get  at  the  ring,  as  it  is  call- 
ed, a  poriion  of  intestine  was  discovered;  it  was  so  small,  as  hard- 
ly to  consist  of  the  whole  diameter  of  the  gut,  but  begirt  very 
tightly.  I  had,  when  the  intestine  was  fairly  in  view,  a  mind  to 
try  whether  1  could  not  return  it  without  dividing  the  tendon, 
and  succeeded  in  the  attempt.  When  this  was  done,  the  consi- 
deration was,  what  to  do  with  the  omentum.  It  was  so  large, 
and  so  affected  by  stricture,  that  it  could  not  repass  the  abdomi- 
nal tendon  without  division:  as  the  gut  was  returned,  it  seemed  a 
pity  to  divide  the  tendon  merely  on  account  of  the  caul:  it  was 
therefore  determined  to  tie  it,  and  cut  it  off. 

The  man  had  a  plentiful  stool  in  an  hour  after  the  operation, 
but  toward  evening,  and  during  the  night,  was  much  out  of  order. 
Next  morning  he  was  hot  and  restless,  had  a  frequent  and  full 
pulse,  complained  of  great  pain  about  his  navel,  and  all  over  his 
belly,  which  was  much  too  tense,  and  he  was  now  and  then 
very  sick. 

Blood  was  drawn  from  him  freely;  he  had  an  oily  laxative 
clyster;  and  Dr.  Pitcairn  directed  for  him.     On  the  third  day,  all 


OBSERVATIOWS  ON  RUPTURES.  40'i 

his  febrile  symptoms,  and  his  pain,  were  much  exaspcraicd,  not- 
withstanding he  had  three  or  four  stools. 

I  think  I  may  venture  to  say,  that  both  the  physician  and  myself 
did  every  thing  in  our  power  for  him;  but  on  the  fourlli  evening 
he  died. 

As  the  case  had  given  me  some  concern,  upon  a  supposition  that 
the  man  might  have  had  a  better  chance,  had  the  tendon  been 
divided  for  the  return  of  the  gut,  I  opened  him  as  soon  as  I  had 
notice  of  his  death,  I  examined  the  whole  intestinal  canal,  and 
found  it  free  from  blemish:  the  peritoneum  was  una.l(ered;  but  all 
that  was  left  of  the  omentum  was  gangrenous. 


CASE  IX. 

A  MAN,  about  thirty-six  years  old,  was  a  patient  in  St.  Bariho- 
lomew's  for  a  sore  leg.  While  he  was  there,  he  desired  me  to 
look  at  a  rupture,  which  he  had  long  had,  and  which  was  clearly 
omental  and  irreducible. 

When  his  leg  was  well,  he  desired  me  to  cut  him,  as  he  called 
it;  alleging,  that  his  rupture  was  so  troublesome,  that  it  prevented 
him  from  following  his  business.  I  refused  it,  and  directed  him  to 
wear  a  suspensory  bag. 

He  solicited  me  again  and  again,  and  at  last,  overcome  by  his 
importunity,  I  performed  the  operation.  The  sac  was  thin,  and 
the  piece  of  omentum  not  large,  nor  at  all  altered,  nor  was  there 
any  thing  else  in  the  bag:  I  made  a  ligature,  and  cut  it  off  with- 
out meddling  with  the  tendon.  From  the  time  of  the  operation  he 
was  in  constant  pain  all  over  his  belly. 

Bleeding,  laxative  medicines,  clysters,  &c.  were  administered, 
but  to  no  purpose.  On  the  fourth  day  he  died,  and  had  no 
appearance  of  mischief  about  him,  except  a  highly  inflamed 
omentum. 

INTESTINAL  HERNIiE. 

When  a  portion  of  intestine,  which  has  passed  out  from  the 
cavity  of  the  abdomen  through  the  opening  in  the  oblique  muscle,. 


408  OBSfcRVATIOlNS  ON  RirPTURES. 

is  so  begirt  as  not  to  be  capable  of  executing  its  jjioper  office, 
the  person,  to  whom  this  happens,  may  be  said  to  be  in  immediate 
danger. 

The  general  offices  of  the  intestinal  tube  are,  digestion  of  the 
food,  formation  of  chyle,  impulsion  of  it  into  the  lacteals,  and  ex- 
pulsion of  the  faeces  forth  from  the  body.  If  these  so  necessary 
functions  are,  for  any  considerable  time,  suspended  or  prevented, 
the  consequence  is  too  obvious  to  need  mentioning:  fortunately  for 
mankind,  this  cannot  happen  unknown  to  us.  Whenever  such 
stricture  is  made,  symptoms  and  complaints  arjse  which  warn  us 
of  our  danger:  pain,  tumefaction,  and  incapacity  of  going  lo  stool, 
are  the  first  and  most  immediate  effects.  If  the  case  be  neglected, 
or  no  proper  remedy  used,  inflammation,  fever,  sickness,  and 
vomiling,  soon  follow;  and  these  are  often,  in  a  short  space  of 
time,  succeeded  by  hiccough,  gangrene,  and  mortification.  Who- 
ever considers  what  the  first  of  these  are  indications  of,  and  knows 
what  will  inevitably  be  the  consequence  if  they  be  not  obviated, 
must  be  sensible,  that  the  very  slightest  attack  of  this  kind  ought 
to  put  us  on  our  guard,  and  excite  us  to  use  our  utmost  endeavours 
to  prevent  further  mischief.  How  long  the  first  and  seemingly 
slightest  symptoms  may  continue  before  material  injury  be  done, 
no  man  can  pretend  to  say:  this  must  depend  upon  a  variety  of 
circumstances,  and  will  be  different  in  different  cases;  but  as  no 
man  can  be  duly  and  intimately  acquainted  with  these  circum- 
stances, and  as  the  change  from  the  most  slight  to  the  most 
hazardous  is  sometimes  very  rapid,  no  one  can  be  vindicated  in 
suffering  the  smallest  portion  of  time  to  be  lost  by  waiting  a  few 
hours. 

Tlie  first  thing  to  be  done  is  to  attempt  the  reduction  of  the  in- 
testine: if  this  fails,  our  next  endeavour  must  be  to  relieve  the 
symptoms,  and  thereby  remove  the  obstruction  to  such  reduction. 

The  means  prescribed  for  this  purpose  are,  phlebotomy,  clysters, 
cathartics,  a  semicupiura  or  warm  bath,  fomentation,  embroca- 
tion, and  cataplasm;  and  these,  by  the  generality  of  our  writers 
of  systems  and  institutes,  are  ordered  indiscriminately,  as  if  their 
efficacy  were  nearly  equal,  and  it  was  a  matter  of  indifference 
which  a  practitioner  made  use  of.  This  I  cannot  conceive  to  be 
true:  some  of  them  are  really  useful;  but  others,  as  far  as  my 


OBSERVATIONS  ON  RUPTURES.  409 

experience  goes,  of  little  or  no  use  at  all.  Among  the  former,  I 
reckon  phlebotomy,  cathartic  medicines,  clysters,  and  the  vvarm 
bath;  among  the  latter,  embrocation,  fomentation,  and  poultice. 
The  former  have  saved  many  a  life:  from  the  latter,  I  never  saw 
any  material  benefit,  though  I  have  often  and  often  tried  them; 
and  I  am  much  inclined  (o  believe,  that  the  use  of  them  has  cost 
many  a  person  dear,  by  occasioning  a  loss  of  that  time  which 
ought  to  have  been  otherwise  employed.  The  inflammation  and 
distention  of  the  intestine  can  never  be  removed  while  it  is  begirt 
by  the  tendon  of  the  abdominal  muscle;  whatever  may  be  the 
original  cause  of  the  stricture,  the  effect  must  be  the  same;  the 
tendon  lies  out  of  the  reach  or  induence  of  a  greasy  poultice;  the 
external  skin  may  indeed  be  relaxed  by  it,  and  some  small  part  of 
the  uneasiness  may  thereby  be  relieved;  but  this  is  of  no  impor- 
tance toward  appeasing  the  symptoms,  lessening  the  hazard,  or 
affording  a  remedy  for  the  original  evil.  The  mere  relaxation  of 
the  skin  will  not  affect  the  stricture  made  by  the  tendon,  the 
warmth  of  the  poultice  will  increase  the  distention,  and  the  in- 
testine will  become  gangrenous,  notwithstanding  a  small  part  of 
the  external  inflammation  may  seem  to  be  appeased.* 

If  the  symptoms  are  neither  such,  nor  so  pressing,  as  to  require 
the  chirurgic  operation;  or  if  the  fears  and  apprehensions  of  the 
patient,  or  of  friends,  prevent  such  operation,  however  necessary 
it  may  be,  the  most  powerful  and  most  efficacious  means  of  obtaining 
relief  are,  phlebotomy,  warm  water,  and  the  exhibition  of  such 
medicines  as  are  likely  to  produce  stools:  by  the  first  we  reduce 
the  strength  of  the  patient,  lessen  the  velocity  of  the  circulating 
fluids,  moderate  the  febrile  heat,  and  take  the  chance  of  a  deli- 
quium;  by  the  second  we  endeavour  to  relax  the  tendinous  open- 
ing by  which  the  intestine  is  begirt;  and  by  the  third,  the  discharge 
of  faeces,  through  the  intestinal  canal,  is  attempted.  The  power 
of  the  two  first  is  clear  and  undoubted;  but  I  cannot  help  thinking, 
that  we  are,  in  some  degree,  wrong  about  the  last.     Cathartic 

'  Cold,  discutieiit  applications  bid  much  fairer  to  retard  the  hasty  pro- 
gress of  the  inflamraation,  than  warm  ones  ;  and  will  be  found  to  answer  the 
purpose  much  better.  Such  as  solutions  of  sal  ammoniac.  Cfud,  in  vinegar, 
the  sp.  mindereri,  the  acet,  l3'tliar!*irit.  and  such  like. 

VOL.    r.  OF 


410  OBSERVATfONS  ON  RUPTURES. 

medicines  have,  in  all  times,  been  prescribed  in  the  case  of  hernia 
with  slrictiire;  but  the  true  intention,  whicli  ought  hy  their  means 
to  be  aimed  at,  does  not  seem  to  have  been,  in  general,  clearly 
understood:  this  perhaps  is  the  reason  why  pracliuoners  and 
writers  disagree  so  much  about  the  kind  of  medicines  which  they 
think  most  proper;  some  advising  those  which  are  of  the  lenient 
unirritating  kind,  others  prescribing  those  which  are  most  stimu- 
lating: both  cannot  be  right,  and  therefore  it  may  be  worth  while 
to  inquire,  what  should  be  the  point  aimed  at,  and  which  are  the 
most  likely  means  to  accomplish  such  end. 

Is  a  discharge,  per  anum,  the  primary  view,  and  therefore  the 
first  object  of  attention?  or  is  such  discharge  to  be  regarded  only 
as  a  necessary  or  natural  consequence  of  the  removal  of  the  intes- 
tine from  its  prison.''  If  the  former  be  the  case,  it  is  clear,  that  in 
the  circumstances  in  which  such  patient  must  be,  stools  cannot  be 
procured  too  soon,  or  by  means  which  are  too  easy;  and  that  such 
medicines  as  are  most  likely  to  slip  through  without  stimulus,  or 
irritation,  must  be  the  most  proper,  and  most  likely,  to  answer  the 
end;  but  if  the  case  be  otherwise,  if  the  first  view  should  be  to 
extricate  the  gut  from  its  stricture,  and  the  discharge  of  faeces  is 
to  be  regarded  only  as  a  necessary  consequence  of  such  removal, 
then,  1  think,  it  is  as  clear,  that  such  lenients  are  unfit,  because 
unequal  to  the  task;  and  that  a  power  or  faculty  of  stimulating  or 
irritating  the  muscular  coat  of  the  intestinal  canal,  ought  to  be 
the  property  of  whatever  is  administered. 

That  a  depletion  of  that  canal  is  a  great  and  immediate  relief 
to  the  patient,  by  unloading  the  belly,  and  lessening  the  tension, 
is  beyond  a  doubt;  and  it  is  as  true,  that,  without  such  discharge, 
the  patient  must  perish,  even  though  the  stricture  be  taken  off; 
but  still  the  two  objects  are  distinct  and  different,  and  the  re- 
movaLor  extrication  of  the  imprisoned  piece  is  clearly  the  first."* 

n*  It  may  not  improperly,  in  this  place,  be  asked,  whether  the  operation  of 
a  purging  medicine  may  not  be  different  from  either  of  these?  and  wliether 
it  may  not  be  in  an  incarcerated  hernia  wliat  it  sometimes  is  in  an  ileus,  where 
it  often  seems  to  act  by  overpowering  that  spasm  which  had  begun  to  excite 
inflammation,  and  would  soon  bring  on  mortification?  What  still  adds  force 
to  .this  method  of  reasoning  is,  the  consideration  of  the  great  relief  always 
obtained  from  a  warm  bath,    ^Yhethe^  this  be  generally  true  or  not,  it  is 


OBSERVATIONS  ON  RUPTURES.  411 

When  purgative  medicines  of  any  kind  are  given  by  the  mouth, 
in  the  case  of  a  strangulated  hernia,  and  do  not  succeed  in  remov- 
ing the  intestine  from  the  stricture,  they  are  either  rejected  by 
vomii,  or,  by  deriving  an  increased  quantity  of  acrimonious  faecal 
matter  downward,  add  to  the  pain  and  tension  of  the  belly. 

This  is  a  very  material  objection  to  the  use  of  all  cathartics 
given  by  the  mouth,  and  more  especially  to  those  whose  bulk  or 
quantity  is  at  all  large;  and  renders  the  application  of  such  kind 
of  medicines  to  that  part  of  the  intestinal  canal  which  is  below 
the  stricture  much  preferable. 

Indeed,  the  superior  advantages  of  stimulating  medicines,  given 
per  anum,  are,  in  this  case,  many  and  great:  they  give  much  less 
disturbance  to  the  stomach,  they  occasion  no  pain  in  the  belly,  nor 
do  they  at  all  increase  the  load  or  tension;  they  may  be  repeated 
frequently;  and,  what  is  of  the  most  consequence,  they  may  con- 
sist of  such  materials  as  cannot  properly,  or  indeed  safely,  be  given 
by  the  mouth.  All  these  are  manifest  advantages;  but  the  last 
circumstance  is  peculiarly  so,  for  the  tobacco-smoke  cannot  pos- 
sibly be  swalloiVed,  nor  would  any  man  in  his  senses  think  of 
putting  the  infusion  into  the  stomach,  although  it  is  well  known, 
not  only  that  both  may  be  very  safely  administered  in  the  form  of 
clyster,  but  that  they  are  the  most  powerfully  efficacious  and  the 
most  useful  medicines  we  are  acquainted  with  for  such  purpose. 

I  have  mentioned  the  smoke  and  the  infusion  of  tobacco  as 
being  equally  useful,  and  have,  from  repealed  experience,  found 
them  so. 

Where  a  proper  machine  is  at  hand,  or  can  easily  be  procured, 
I  should  certainly  prefer  the  smoke  to  the  infusion;  because,  the 
effects  which  both  are  apt  to  produce  on  the  nervous  system  of 
the  patient  are,  I  think,  lighter  in  the  former  than  in  the  latter; 
but  where  such  machine  has  not  been  at  hand,  nor  could  be  pro- 
cured without  a  loss  of  time,  which,  in  these  cases,  is  always  pre- 
cious, I  have  frequently  used  the  infusion,  and  generally  very  suc- 
cessfully.    The  symptoms  arising  from  the  intoxicating  quality 

certainly  well  worth  consideration.  May  not  from  this  also  be  inferred  the 
reason  why  opium,  joined  with  purgatives,  is  sometimes,  in  the  same  disease, 
found  to  render  the  operation  of  the  latter  more  successful? 


412  OBSERVATIONS  ON  RUPTURES,  • 

of  the  tobacco,  the  languor,  the  cold  sweat,  &c.  which  this  weed 
causes,  more  esjieiialiy  in  those  who  have  not  been  accustomed  to 
it,  are,  as  I  have  said,  I  think,  rather  more  from  the  infusion  than 
from  the  smoke;  but,  though  I  have  often  used  it.  I  do  not  remem- 
ber ever  to  have  seen  any  ill  eflect  from  it.  It  generally  makes 
the  patient  very  sick,"  and  produces  a  fainting  and  a  cold  sweat, 
ivhich,  to  those  who  do  not  immediately  reflect  on  the  intoxicating 
quality  of  tobacco,  and  the  symptoms  of  such  intoxication,  may 
appear  alarming;  but,  whether  ii  be  from  the  swooning,  or  from 
the  irritation  made  in  the  intestinal  canal,  or,  which  is  much  more 
likely,  from  both  conjointly,  I  have,  several  times,  seen  ruptures, 
which  have  resisted  all  attempts  by  the  hand,  return,  of  them- 
selves, untouched,  during  the  influence  of  such  clyster. 

Many  other  stimulating  applications  to  the  rtctum  I  have,  at 
different  times,  made  trial  of,  but  never  found  any  at  all  equal,  in 
effect,  to  the  tobacco;  nor  did  I  ever  see  any  of  them  produce  that 
convulsive  motion  of  the  muscles  of  the  abdomen,  which  most 
frequently  accompanies  the  sickness  attending  the  use  of  this 
weed,  and  which,  although  fatiguing  and  troublesome  while  it 
lasts,  yet  is  certainly  one  of  the  means  whereby  the  extrication  of 
the  portion  of  intestine  is  accomplished. 

I  have  also  several  times  seen  them  both  fail,  after  fair  and  re- 
peated trial.  Whoever  expects  infallibility  in  medicine  will  be 
disappointed;  but  I  can,  with  truth,  affirm,  that  I  have  seen  both 
the  smoke  and  the  infusion  succeed  much  oftener  than  any  thing 
else,  arfd  sometimes  in  very  desperate  cases. 


CASE  X. 

I  vvls  desired  to  visit  a  ruptured  patient  with  Mr.  James,  then 
surgeon  to  St.  Luke's  hospital. 

The  patient  was  a  stout,  healthy  man,  about  thirty;  the  rupture 
was  large,  hard,  painful,  and  beginning  to  be  inflamed  on  the  out- 
side; no  stool  had  passed  for  two  days;  the  man  had  great  pain  all 

"  The  infusion,  which  1  have  always  used,  has  been  made  by  pouring  one 
pint  of  boiling  water  on  one  drachm  of  tobacco. 


OBSERVATIONS  ON  RUPTURES.  413 

over  his  belly,  and  a  frequent  vomiting.  Mr.  James  had  many 
times  (ried  to  reduce  it;  he  had  bled  him  freely;  and  had  given 
both  purges  and  clysters,  but  all  without  eflect. 

The  scrotum  was  exceedingly  tense,  and  the  pain  which  at- 
tended the  most  gentle  handling  was  so  exquisite,  as  not  only  to 
render  all  attempts  for  reduction,  by  the  hand,  improper,  but  ha- 
zardous. 

Ii  was  about  noon  when  I  saw  the  man:  every  thing  except  the 
tobacco  had  been  tried;  the  symptoms  were  advancing  hastily,  and 
the  operation  was  proposed  and  submitted  to;  but,  while  our 
things  were  getting  ready,  we  thought  we  might  as  well  try  the 
smoke  clyster. 

One  ounce  of  tobacco  was  expended  without  any  effect  at  all, 
either  general  or  local;  but,  toward  the  consumption  of  another, 
the  patient  became  sick  and  faint,  and  complained  of  a  strange 
kind  of  motion  in  his  belly,  and  also  in  his  rupture.  Upon  turn- 
ing the  bed-clothes  back,  the  motion  was  not  only  to  be  felt  within 
th<  scrotum,  but  was  even  visible;  this  motion  continued  about  two 
minutes,  when  the  intestine,  without  being  touched,  returned;  the 
man  became  immediately  easy;  and,  in  half  an  hour,  had  a  plenti- 
ful discharge  per  anum. 


CASE  XL 

In  the  month  of  September,  1767,  I  was  sent  for  in  a  hurry  to 
some  little  distance  from  London,  in  order  to  perform  the  opera- 
tion for  the  bubonocele. 

I  found  a  very  large  rupture  on  the  right  side,  and  that  in  so 
painful  a  state,  as  not  to  permit  the  most  gentle  handling.  The 
patient  had  been  treated  with  the  greatest  propriety,  had  been 
freely  and  repeatedly  let  blood,  had  taken  purging  medicines, 
clysters,  &c.  and  had  been  several  times  in  a  bathing  tub:  his 
vomiting  was  frequent,  he  had  a  tendency  to  a  hiccough,  and  he 
could  not  bear  to  extend,  in  the  smallest  degree,  the  thigh  on  the 
ruptured  side. 

The  operation  had  been  consented  to  before  I  had  been  sent  for; 
but,  upon  my  asking  the  gentleman  who  attended,  if  he  had  a  ma- 


414  OBSERVATIONS  ON  RUPTURES. 

chine  for  giving  the  tobacco-smoke  clyster,  and  being  answered  in 
the  affirmative,  we  determined  to  try  it  first. 

When  about  half  an  hour  had  been  spent  in  the  continual  im- 
pulsion of  the  smoke,  the  man  cried  out,  '  My  rupture  is  going 
up!'  and,  in  the  space  of  two  or  three  minutes,  it  did  so,  with  a 
noise  which  was  heard  by  every  one  in  the  room. 


CASE  XII. 

A  GENTLEMAN,  whom  I  had  long  known,  had  often  showed  me 
a  rupture,  which  he  had  laboured  under  as  long  as  he  could  re- 
member, and  which  was  now  and  then  troublesome  to  him,  be- 
cause he  could  not  wear  a  truss  to  keep  it  within  the  abdomen. 
It  was  of  the  congenial  kind;  that  is,  the  sac  of  the  hernia  was 
formed  by  what  should  have  been  the  tunica  vaginalis  testis.  But 
his  testicle,  on  that  side,  had  never  descended  from  the  groin,  but 
lay  just  on  the  outside  of  the  abdominal  opening;  neither  had  the 
portion  of  intestine  got  any  lower,  so  that  both  of  them  lay  to- 
gether: on  which  account,  he  not  only  never  could  wear  a  truss, 
but  even  the  waistband  of  his  breeches,  if  buttoned  tight,  was  trou- 
blesome. 

This  gentleman  was  suddenly  seized  with  the  symptoms  of  a 
stricture,  and  those  not  slight,  even  at  the  first  attack.  The  piece 
of  intestine,  though  always  in  the  groin  when  he  was  in  an  erect 
posture,  had  always  gone  up  upon  his  going  to  bed,  and  was  al- 
ways returnable  when  he  was  supine.  He  tried  now  to  reduce 
it  as  usual.  He  sent  for  me,  and  all  my  attempts  were  equally 
successless.  His  belly  was  very  hard,  he  began  to  vomit,  and  the 
testicle  became  very  painful  to  the  touch. 

All  the  circumstances  were  disagreeable,  the  symptoms  ad- 
vanced wiih  uncommon  rapidity,  the  portion  of  gut  was  small,  the 
testicle  inflamed  and  somewhat  enlarged:  an  operation  might 
become  necessary,  but  could  not,  in  such  circumstances,  be  de- 
sirable. 

He  was  bled  freely,  even  to  swooning;  purging  medicines  were 
given,  and  immediaiely  rejected;  clysters  had  no  eifect,  but  were 


OBSERVATIONS  ON  RUPTURES.  416 

as  immediately  returned;  and  the  patient,  knowing  his  own  situa- 
tion, was  much  alarmed. 

Dr.  de  la  Cour,  who  was  his  physician,  was  called  in,  and 
having  tried  the  tobacco- smoke  ineffectually,  we  agreed  to  throw 
up  a  pint  of  the  infusion,  made  as  before  related.  It  soon  made 
him  exceedingly  sick  and  faint,  and  caused  a  large  discharge  of 
wind,  upward  and  downward,  from  which  I  expected  a  return  of 
the  gut,  but  in  vain.  At  the  distance  of  an  hour,  or  two,  the  in- 
fusion was  repeated,  with  the  same  effect  of  faintness  and  sick- 
ness, during  which  he  was  put  into  warm  water;  and  when  he 
had  been  in  it  a  few  minutes,  the  slightest  application  of  the  hand 
obtained  immediate  reduction,  and  stools. 


CASE  XIII. 

The  late  Mr.  Fullager  desired  me  to  go  with  him  to  see  a 
wine-merchant  in  Billiter-lane,  who  had  all  the  symptoms  of 
strangulation  in  the  case  of  a  scrotal  hernia,  and  whose  rupture 
he  had  ineffectually  endeavoured  to  reduce.  I  tried,  and  was 
also  foiled.  The  symptoms  were  rather  pressing.  Mr.  Smith, 
in  Cheapside,  who  had  been  the  apothecary  to  Mr,  James's  patient, 
was  also  apothecary  here.  It  was  determined  that  I  should  meet 
Mr.  Fullager  again,  in  about  three  hours,  in  order  to  perform  the 
operation;  and  that,  in  the  mean  time,  Mr.  Smith  should  throw 
up  the  tobacco-smoke.  At  the  appointed  time  we  met,  and 
found  Mr.  Smith  employed  as  we  had  desired;  I  laid  my  hand  on 
the  rupture  to  examine  the  state  of  it,  and  it  was  wonderful  with 
what  facility  it  went  up. 

The  same  thing,  exactly,  happened  to  me  with  a  coachman  of 
the  late  Dr.  Nicol  of  the  Charter-house:  but  the  same  man,  upon  a 
return  of  the  complaint,  at  about  two  years  distance,  was  not 
again  so  fortunate;  the  smoke  and  infusion  both  failed,  and  the 
operation  was  performed;  but  too  late. 


It  is  as  yet,  with  many,  a  disputed  point,  in  the  case  of  incarcer- 
ation of.  a  portion  of  intestine  in  a  hernia,  whether  the  stricture 
made  by  the  tendon  be  original  or  consequential;  or,  in  other 


41t>  OBSERVATIONS  ON  RUPTURES. 

words,  wlietlier  (he  disease  be  not  ftriginally  in  the  intestine,  and 
the  stricture  a  mere  effect  of  its  dislodgemenl  and  distention. 
The  arguments  used  in  support  of  the  latter  opinion  are  bv  no  means 
void  of  force,  but  at  the  same  time  I  cannot  think  them  conclu- 
sive. The  perfect  health  and  ease  of  many,  nay  of  every  body, 
immediately  before  a  sudden  descent,  the  very  pressing  and  alarm- 
ing symptoms  with  which  such  descent  is  often  attended  almost 
instantaneously,  and  the  relief  which  reduction  immediately  pro- 
duces in  the  majority  of  such  cases,  together  with  the  immediate 
and  total  removal  or  dissipation  of  all  the  evils  occasioned  by  the 
confinement,  seem  to  prove  the  general  opinion  (o  be  true. 

On  the  other  hand,  the  perfectly  quiet,  easy,  and  uncompressed 
state  of  the  parts,  in  many  instances,  immediately  previous  to  the 
invasion  of  bad  symptoms,  in  cases  where  there  has  been  no 
exertion  of  strength,  nor  any  apparent  accession  of  a  larger  and 
new  portion  of  gut,  are  circumstances  which,  added  (o  the  inca- 
pacity of  the  tendon  to  contract,  are  well  worth  weighing,  as  they 
certainly  give  force  to  the  former  supposition. 

As  a  mere  point  of  speculation,  it  is  not  perhaps  a  matter  of 
very  great  importance;  but  when  considered  as  applied  to  prac- 
tice, and  influencing  our  conduct  with  regard  to  the  chirurgic 
operation,  it  becomes  very  interesting  indeed. 

When  the  hand  and  the  common  means  for  reduction  fail,  the 
operation  is  our  only  resource,  and  if  applied  to  in  time,  very  sel- 
dom fails;  so  seldom,  that  I  believe  I  might  venture  to  say,  not 
one  in  fifty"  dies  of  it,  if  timely  and  judiciously  executed;  and 
when  it  becomes  absolutely  necessary,  it  is  the  unicum  remedium. 
This  consideration  renders  it  a  matter  of  still  more  importance; 
for  as  in  cases  where  it  becomes  necessary  and  our  only  hope,  it 
ought  always  to  be  proposed;  for  the  same  reasons,  in  cases  where 
it  is  not  necessary,  it  ought  not  to  be  thought  of;  and  where  it 
cannot  be  of  use,  it  ought  not  to  be  done. 

The  intestinal  tube,  whether  within  the  belly  in  its  natural  si- 
tuation, or  thrust  forth  from  it  in  the  form  of  hernia,  is  liable  to 
diseases  whose  symptoms  are  peculiar  to  itself.  Where  there  is 
no  hernia,  nobody  doubts  concerning  the  nature  of  the  case;  but 

"  T  mean  of  tlie  operation  consklerecl  abstractedly. 


OBSERVATIONS  ON  RUPTURES.  417 

where  there  is  one,  from  the  simiiarily  of  the  symptoms,  it  always 
takes  the  blame;  offen  deservedly,  sometimes  much  the  contrary. 

In  the  case  of  old,  unrechiced  hernias,  there  is  no  reason  why 
the  portion  of  intestine,  forming  such  complaint,  should  be  exempt 
from  such  distempers  as  the  canal  is  liable  to:  on  the  contrary,  it 
is  reasonable  to  suppose,  that  by  such  unnatural  situation  and  con- 
finement, it  would  become  rather  more  liable.  But  be  this  as  it 
may,  certain  it  is,  that  inflammation  of  the  intestine,  violent  dis- 
tention of  it,  with  loss  of  peristaltic  motion,  and  stoppage  of  stools, 
is  sooielimes  the  case  in  a  hernia  where  the  abdominal  tendon  has 
no  share  in  the  mischief;  and  as  certain  it  is,  that  in  such  case  the 
operator  can  do  no  good.  In  some  instances  this  mav,  by  atten- 
tive inquisition,  be  learned,  and  the  operation  thereby  preserved 
from  a  disgrace:  in  others,  it  can  only  be  known  by  its  proving 
unsuccessful. 

When  the  disease  is  the  mere  consequence  of  stricture,  and  the 
gut,  previous  to  such  stricture,  was  free  from  distemper,  it  seldom, 
I  might  almost  venture  to  say  never,  happens:  but  that  the  setting 
it  free  is  followed  by  a  discharge  peranum,  especially  if  such  in- 
tention be  properly  assisted.  But  when  the  disease  was  originally 
in  the  intestine,  and  the  intestine  either  not  bound  by  any  stric- 
ture, or  a  stricture  the  mere  consequence  of  the  previous  distemper 
of  the  gut,  it  most  frequently  happens  that  such  discharge  does  not 
follow  the  operation^  nor  is  obtainable  by  any  means  after  it.  This 
I  have  always  regarded  as  a  characferistic  mark  of  the  true  nature 
of  the  malady;  to  which  I  think,  from  what  I  have  seen  of  those 
cases,  I  might  add  another,  which  is  the  great  difficulty,  and,  in 
some  cases,  impossibility  of  keeping  the  reduced  intestine  (after 
the  operation)  within  the  belly — a  circumstance  which  I  have 
seen  sometimes  to  be  absolutely  imj)ossible.  In  the  cases  where 
all  the  mischief  arises  from  the  mere  prolapsus  and  stricture,  the 
returned  intestine  becomes  immediately  pervious,  and  enjoying  its 
peristaltic  motion,  keeps  its  place,  and  does  its  office;  but  where, 
by  previous  distemper,  it  is  rendered  impervious,  and  deprived  of 
its  motion,  it  cannot  execute  its  office,  it  remains  violently  dis- 
tended, and  is,  with  great  difficulty,  kept  within  the  belly,  of 
Avhich  I  could  give  many  instances.  This  is,  on  several  accounts, 
a  matter  of  importance,  both  to  patient  andsuraeon:  with  regard 

VOL,.  I,  3  G 


■il8  OBSERVATIONS  ON  RUPTURES. 

1o  the  ibrmer,  it  is  not  merely  the  alarm,  anxiety,  horror,  and 
pain,  which  necessarily  attend  an  operation  of  such  kind,  and  of 
such  serious  consequence,  and  which,  of  themselves,  are  surely 
enough:  but  the  distemper  not  residing  in,  nor  being  produced  by 
the  stricture,  the  necessary  symptomatic  fever  attending  such  an 
operation  must,  in  the  nature  of  things,  be  a  circumstance  of  ad- 
ditional hazard:  and  with  regard  to  the  surgeon,  the  difficulty  of 
returning  the  distended  intestine,  and  of  keeping  it  in  the  belly 
after  it  has  been  returned,  together  with  tlie  most  frequent,  and 
indeed  most  probable,  event  iS  such  case,  render  it  very  unplea- 
sant, and  what  every  man  would  choose  to  avoid.  No  man  can 
command  success;  but  every  man  would  wish  to  be  in  the  vvav 
of  it. 

CONGENIAL  HERNLE. 

The  diiference  between  these  and  other  ruptures,  is  not  a  matter 
of  mere  anatomical  speculation:  there  are  in  the  former  several 
particularities  which  require  a  practitioner's  very  serious  attention, 
and  which  an  operator  ought  always  to  be  aware  of. 

The  sac  of  a  common  hernia,  every  one  knows,  is  formed  by 
the  protrusion  of  the  peritoneum,  through  the  natural  opening  in 
the  tendon  of  the  external,  oblique  muscle  of  the  abdomen.  This 
sac,  at  first,  extends  no  further  than  the  sroin,  but  is,  by  means  ot 
its  contents,  gradually  pushed  low^er  and  Tower  until  it  gets  into 
the  scrotum.  It  always  lies  anterior  to  ihe  spermatic  vessels,  and 
is  enveloped  in  the  cellular  membrane,  which  makes  the  tunica 
communis  of  the  said  vessels,  forms  a  cavity  perfectly  distinct 
from  the  tunica  vaginalis  testis,  and  never  does  or  can  contain  the 
testicle  within  it. 

In  the  congenial  hernia,  the  case  is  different:  in  this,  the  sac 
is  not  formed  by  the  unnatural  protrusion  of  a  portion  of  the 
peritoneum,  which  ought  to  have  remained  within  the  belly,  but 
is  made  by  the  unclosed  vaginal  coat  of  the  testicle;  consequently 
the  said  sac,  constantly  and  necessarily,  contains  within  it  the 
testicle,  together  with  whatever  else  may  have  passed  from  the 
abdomen  to  constitute  the  hernia,  and  which  parts  must  therefore 
be  in  contact  with  the  testicle. 


OBSERVATIONS  ON  RUPTURES.  -^IS 

From  this  particularity  result  some  circumstances  very  ne- 
cessary for  a  practitioner  to  be  acquainted  witb.  Such  are  the 
following: — 

1.  It  sometimes  happens,  that,  in  infants,  a  portion  of  intestine 
slips  down  along  with  the  testicle,  prevents  the  closing  of  the  tunica 
vaginalis,  and  thereby  constitutes  the  disease. 

3.  It  sometimes  happens,  that  a  portion  of  gut  only  comes  down, 
the  testicle  never  passing  forth  from  the  abdomen,  or  remaining  in 
the  groin,  and  falling  no  lower. 

3.  In  this  species  of  hernia  a  stricture,  or  strictures,  are  some- 
times met  with,  which  are  formed  merely  by  the  contraction  or 
coarctation  of  the  neck  of  the  vaginal  coat  or  sac,  independent  of 
the  abdominal  tendon.     And, 

4.  The  parts  contained  in  a  common  hernia  are  liable  to  con- 
tract cohesions  with  each  other,  or  wilh  the  sac;  but  in  the  con- 
genial both  omentum  and  gut  are  liable  to  become  connected  with 
the  testicle;  which  connexion  will,  sometimes,  demand  all  the 
judgment  and  all  the  dexterity  of  an  operator.  So  that,  nice  and 
delicate  as  the  operation  of  a  bubonocele  is  in  the  most  simple 
and  common  case,  it  becomes  much  more  so  in  the  congenial 
rupture. 


CASE  XIV. 

A  BOY,  about  fourteen  years  old,  was  taken  into  St.  Bartho- 
lomew's hospital  for  a  strumous,  lumbal  abscess,  the  matter  of 
which  had  made  its  way  out  in  the  upper  part  of  the  thigh.  The 
discharge  was  great,  and  the  boy  sinking  apace. 

While  he  lived  I  took  notice  of  a  particular  appearance  on  one 
side  of  the  scrotum. 

The  spermatic  process,  at  its  exit  from  the  belly,  was  large  and 
full,  and  plainly  contained  something  which  should  not  be  there; 
immediately  below  the  fulness,  the  process  was  of  little  more  than 
its  natural  size;  but  just  above  the  testicle,  it  was  again  consider- 
ably enlarged,  and  had  the  same  feel  as  above. 

The  true  state  of  the  case  remained  in  doubt  till  the  boy  died,  ' 


420  OBSERVATIONb  ON  RUPTURES. 

at  which  time   both   the  swellings  were  become  inanifesliy  less 
than  they  had  been. 

I  opened  his  body,  and  examined  the  parts  with  some  care. 
The  tunica  vaginalis  testis  was  open  to  the  abdomen,  and  con- 
tained a  considerable  portion  of  omentum,  which  portion  reached 
quite  down  to  the  testicle,  but  did  not  adhere  to  it:  in  the  mid- 
way, between  the  abdominal  opening  and  the  testis,  the  hernial 
sac  was  so  contracted,  that  the  piece  of  caul,  embraced  by  the 
contraction,  was  not  extricable  by  any  force,  and  was  pressed  into 
a  firm,  hard  substance:  above  and  below,  it  was  soft  and  expan- 
sile, but  void  of  fat,  as  in  all  emaciated  subjects.  This  hernia, 
therefore,  added  to  its  other  particularities,  must  have  been  inca- 
pable of  reduction  without  an  operation. 

Much  about  the  same  time,  Mr.  Reiley,  a  very  ingenious  gen- 
tleman, who  was  then  under  me  at  St.  Bartholomew's,  showed 
me  a  congenial  hernia  in  a  child  he  had  then  in  dissection,  and 
in  which  a  portion  of  intestine  was  begirt  in  the  same  manner,  so 
as  to  be  perfectly  inextricable  but  by  division  of  the  part. 

Had  the  child  lived,  and,  at  any  time,  been  under  a  necessity 
of  submitting  to  the  operation  for  a  bubonocele,  this  stricture, 
made  by  the  sac  only,  and  independent  of  the  abdominal  tendon^ 
might  have  proved  a  very  embarrassing  circumstance  in  the  ope- 
ration, and  have  occasioned  a  difficulty  which  might  not  have 
been  foreseen;  indeed,  upon  a  view  of  it  after  death,  it  appeared 
wonderful,  how  the  intestine  had  executed  its  otfice  during  the 
child's  short  life. 


CASE  XV. 

Thomas  Lever,  a  lad  about  seventeen  years  old,  was  sent  to 
St.  Bartholomew's  by  Mr.  Gray,  of  Colchester.  His  complaint 
was  a  rupture,  which  prevented  his  getting  his  bread,  and  which 
nobody  in  the  country  had  been  able  to  reduce. 

The  account  he  gave  of  himself  was  as  follows:  That  he  had 
had  the  rupture  as  long  as  he  could  remember;  that  it  had  always 
been  down  in  the  day,  and  up  in  the  night,  until  within  about  six 
months  past,  when  he  had  been  thrown  over  a  horse's  head,  and 


QBSERVATIONS  ON  RUl'TURES.  421 

bruised  against  the  pummel  of  the  saddle;  that  the  blow  gave  him 
so  great  pain  at  the  time  as  to  occasion  his  swooning;  that  the 
pain  continued  some  hours,  and  was  followed  by  inliammation 
and  swelling,  which  lasted  some  days;  and  that,  from  that  time, 
he  had  never  been  able  to  get  his  rupture  up. 

The  scrotum  was  large  and  full,  but  not  at  all  tense:  it  plainly 
contained  a  portion  of  intestine,  but  there  was  no  symploin,  nor 
any  appearance  of  the  smallest  degree  of  stricture.  Upon  attempt- 
ing reduction,  some  part  of  the  gut  passed  easily  and  freely  into 
the  abdomen,  but  a  considerable  portion  of  it  remained,  nor  could 
by  any  means  be  made  to  follow.  The  testicle  was  very  distin- 
guishable below,  and  seemed  to  be  of  its  natural  size,  and  in  a 
natural  state,  except  that  from  the  epididymis  there  proceeded  a 
small,  hard  body,  which  body  became  tight  when  the  returnable 
part  of  the  gut  went  into  the  belly,  and  seemed  to  be  what  hin- 
dered the  return  of  the  whole.  The  boy  was  in  perfect  health, 
had  no  obstruction  to  his  discharge  per  anum,  nor  any  complaint 
relative  to  the  intestinal  canal.  A  part  of  the  intestine  was,  as  I 
have  already  said,  returnable  with  the  greatest  ease;  but  even 
this  would  not  remain  a  moment  after  the  finger  which  returned 
it  was  removed,  not  even  in  a  supine  posture.  A  complete  re- 
duction was  found  impracticable — the  parts  were  in  such  a  state, 
that  no  benefit  could  be  proposed  from  evacuation  of  any  kind. 
To  put  a  truss  on  was  not  only  useless,  but  mischievous;  and  to 
leave  a  boy  of  seventeen,  who  was  to  get  his  bread  by  hard  la- 
bour, with  his  scrotum  loaded  with  intestine,  liable,  by  every  ex- 
ertion, to  be  increased,  and  by  any  inflammation  to  become  stran- 
gulated, could  not  be  thought  of. 

It  was  therefore,  after  very  mature  deliberation,  deemed  ad- 
visable to  give  him  the  very  probable  chance  of  a  cure  by  an  ope 
ration. 

The  very  easy  return  of  part  of  the  gut  into  the  belly  convinced 
me,  that  I  must  not  expect  to  find  any  fluid  in  the  sac:  and  the 
boy's  own  account  satisfied  me  that  the  hernia  was  congenial, 
and  had  the  tunica  vaginalis  for  its  sac. 

I  made  my  incision  very  cautiously,  and  found  both  these  cir- 
cumstances to  be  true.  In  the  bag  was  a  small  portion  of  the 
ileum,  and  that  part  of  the  colon  called  the  caecum,  with  its  ap- 


422  OBSEKVAIIOWS  ON  RUPTURKis. 

pendicuia  vci'miformis:  the  former  was  loose,  but  the  latter  was 
adherent  io  (he  epididymis  and  testicle.  It  took  some  little  time 
to  separate  these  connexions  in  such  manner  as  to  injure  neither 
of  the  par!s;  but  when  that  was  accomplished,  a  very  small  di- 
vision of  the  tendon  served  to  obtain  a  complete  reduction  of  the 
whole,  and  the  boy  went  home  well  in  about  six  weeks. 

If  this  lad  liad  not  undergone  the  operation  at  the  time  he-did, 
and  inllaraniation  \vi(h  shicUire  had,  at  any  future  time,  attacked 
him,  his  chance  of  preservation  would  have  been  but  small.  The 
adhesion  would  have  rendered  reduction  impracticable;  but  this 
not  being  known,  would  have  at  least  occasioned  a  waste  of  time 
in  unnecessary,  fruitless  attempts,  &c.;  unless  it  maybe  supposed 
that,  after  such  attack,  ihe  intestine  could  be  rendered  pervious 
and  capable  of  executing  its  office  by  means  of  purging  and  stimu- 
lating medicines,  (which  in  this  situation  of  things  I  am  not  much 
inclined  to  believe,)  it  is  clear,  that  nothing  but  the  operation 
could  iiave  served  him;  which  operation  (the  circumstance  of  ad- 
hesion not  being  known)  would  not  in  all  probability  have  been 
proposed  one  minute  too  soon.  Besides  which,  when  all  the  parts 
were  got  into  a  state  of  infias'amation,  the  separation  of  the  cohe- 
sion might  not,  perhaps,  have  been  executed  so  readily. 

A  case,  in  some  degree  like  to  this,  was  in  St.  Bartholomew's 
about  a  year  ago,  under  the  care  of  Mr.  Younge.  It  was  in  a  boy 
about  eleven  years  old.  His  scrotum  was  much  enlarged,  and 
contained  something  of  considerable  size;  but  there  was  neither 
pain,  iniiammalion,  tension,  nor  impediment,  in  going  to  stool. 
Notwithstanding  the  absence  of  all  bad  symptoms,  the  boy,  from 
the  mere  size  of  the  tumor,  was  prevented  from  doing  any  thing, 
either  by  way  of  exercise  or  work. 

The  operation  was  performed:  the  hernia,  which  vvas  conge- 
nial, was  both  intestinal  and  omental.  1  am  sure  I  am  within  the 
truth  when  I  say,  that  there  were  ten  different  adhesions  of  the 
omentum  to  the  sac,  and  two  to  the  testicle:  nor  was  this  all,  for 
the  upper  part  of  the  sac  was  so  narrow,  that  it  might  well  have 
been  mistidcen  for  a  stricture  made  by  the  tendon. 

Had  the  portion  of  intestine  in  this  case  been  at  any  time  in- 
creased, so  as  to  have  produced  a  stricture,  bad  symptoms  would 


OBSERVATIONS  ON  RUPTUFJiS.  423 

soon  have  come  on,  and  what  (.rouble  might  not  have  been  expect- 
ed from  parts  so  circumstanced,  not  one  of  which  couki  liave  been 
known  previously  to  the  operation?  > 

A  sudden  attack  of  great  pain  in  t'ne  belly,  attended  with  sick- 
ness and  vomiting,  and  an  incapacity  of  going  to  stool,  imply  the 
probability  of  a  rupture  being  the  cause;  especialiy  if  the  person 
so  attacked  either  has  at  that  time,  or  has  had,  one. 

Pain  in  the  belly,  nausea,  vomiting,  and  constipation,  are  the 
general  symptoms  of  an  obstruction  in  some  part  of  the  intestinal 
canal,  and  denote,  among  other  things,  a  perversion,  alteration, 
and,  perhaps,  sometimes,  cessation  of  its. peristaltic  motion.  They 
do  not  indeed  point  out  what  the  particular  cause  may  be;  but, 
let  it  be  what  it  may,  if  it  be  not  soon  removed,  the  patient  must 

sink. 

An  incarcerated  hernia,  as  it  is  called,  is  a  disease  caused  by 
such  stricture  made  on  a  part  of  the  intestinal  canal,  as  not  only 
stops  its  proper  motion,  and  prevenis  the  passage  of  the  faeces 
through  it,  but  also  hinders  the  circulation  of  blood  through  its 
vessels,  and  very  soon  induces  a  mortification. 

The  same  symptoms  have  sometimes  been  produced  by  an  in- 
flammation, or  by  a  spasmodic  aftection  of  the  same  part  in  per- 
sons who,  if  they  have  had  a  hernia,  have  not  had  any  s!ricture 
in  it;  and  also  in  persons  who  have  had  no  hernia  at  all. 

The  great  and  material  difference  between  the  two  cases  is,  that 
in  the  one  the  symptoms  are  occasioned  by  an  affection  of  a  part 
of  the  intestinal  tube  thrust  forth  from  lis  natural  situation  within 
the  belly,  and  begirt  by  a  stricture;  and,  in  the  o-lher,  they  arise 
from  an  affection  of  a  part  of  the  same  canal,  not  begirt  nor  thrust 
forth,  but  remaining  in  its  proper  place.  The  general  complaints 
attending  each  of  these  diseases  are  so  alike,  and  are  so  very  diifi- 
cult  to  be  distinguished  from  each  other,  that  whenever  they  ap- 
pear to  any  violent  degree,  the  places  in  which  hernijB  make  theij* 
appearance,  ought  always  to  be  inquired  into  or  esamined,.  more 
especially  in  women;  for,  although  the  symptoms  resemble  each 
other  so  much,  the  causes  of  them  are  materially  different,  and  ren- 
der one  an  object  of  surgery,  while  the  other  is  not  at  all  so. 
Whoever  reflects  on  these  facts  must  see  the  propriety,  or  indeed 


424  OBSERVATIONS  ON  RUPTUREb.- 

the  necessil}',  of  such  inquiry  as  may  determine  tbe  true  nature  ot' 
the  malady;  that  a  rupture,  if  it  be  the  cause,  may  be  immediately 
reduced;  or,  ihat  not  being  the  case,  that  the  passio  illiaca  may  be 
properly  treated. 

These  circumstances  are  such,  that  the  hazard  or  safety  of  the 
patient  often  depends  upon  them,  and  therefore  require  the  very 
serious  attcnllon  of  the  practitioner:  but,  material  as  they  are, 
they  are  not  all:  there  are  others  which  equally  demand  his 
regard.!* 

A  rupture  doth  not  preclude  or  prevent  inflammation  or  spasm, 
or  whatever  else  may  be  the  cause  of  mischief,  from  attacking  any 
other  part  of  the  intestinal  canal  not  included  within  the  hernial 
«ac;  neither  doth  it  prevent  the  same  kind  of  evils  from  falling  on 
that  part  of  the  intestine  which  is  within  the  sac,  and  thereby  pro- 
ducing mischief  independent  of  the  rupture,  although  affecting  the 
part  within,  or  causing  it.  And  it  also  sometimes  happens,  that 
persons  afflicted  with  unreduced  or  irreducible  ruptures,  are  ren- 
dered incapable  of  discharging  their  faeces  per  anum,  by  causes 
y>fhich  have  not  the  least  connexion  with,  or  dependence  upon  the 
rupture,  or  the  intestine  contained  within  it.  Thus  it  becomes  a 
surgeon's  care  to  endeavour  to  be  able  not  only  to  know  when  a 
hernia  is  the  cause  of  bad  symptoms,  but  also  when  it  is  not;  as 
his  conduct  upon  these  different  occasions  must  be  very  materially 
different:  for,  on  the  one  hand,  if  the  mischief  arises  from  the  in- 
testine being  bound  by  a  stricture,  nothing  but  the  reduction  of  it 
by  the  hand,  or  the  setting  it  free  by  the  chirurgic  operation,  can 
preserve  the  patient;  but,  on  the  other,  if  the  symptoms  proceed 
from  another  cause,  even  though  the  portion  of  intestine  within  the 
hernia  should  be  the  immediate  seat  of  the  evil,  the  attempts  for 
reduction  will  be  painful  and  vain,  the  operation  at  best  useless, 
and  most  probably  prejudicial;  and,  if  the  seat  and  cause-of  the 
mischief  be  not  within  the  rupture,  both  the  last  mentioned  at- 
tempts become  thereby  still  more  improper,  more  useless,  and 
more  pernicious. 

P  Tlie  observation  of  Platner,  who  says,  "Nee  facile  liiveniuntur  notze  qu<e 
'  ostenduut  ex  qua  occasione  intes'dna  laborant,"  is  strictly  just  and  true. 


OBSERVATIONS  ON  RUPTURES.  425 


CASE  XVI. 

An  old  gentleman,  who  bad  for  many  years  had  an  irreturnable 
rupture  of  the  mixed  kind,  and  which  I  had  often  seen,  was 
seized  with  the  symptoms  of  an  obstruction  in  the  intestinal  canal. 

He  complained  of  great  pain  in  his  whole  belly,  but  particu- 
larly about  his  navel.  He  was  hot  and  restless,  and  had  a  fre- 
quent inclination  to  vomit;  his  pulse  was  full,  hard,  and  frequent; 
and 'he  had  gone,  contrary  to  his  usual  custom,  three  days  without 
a  stool. 

I  examined  his  rupture  very  carefully;  the  process  was  large  and 
full,  as  usual,  but  not  at  all  tense  or  painful  upon  being  handled; 
his  belly  was  much  swollen  and  hard,  and  he  could  hardly  bear 
the  light  pressure  of  a  hand  about  his  navel.  Upon  mature  con- 
sideration of  the  whole,  I  was  of  opinion  that  his  rupture  had  no 
share-  in  his  present  complaints.  But  as  some  of  his  symptoms 
resembled  those  of  a  stricture,  I  desired  that  more  advice  might' 
be  had.  A  physician  and  surgeon  were  called:  I  gave  them  an 
account  of  what  I  had  seen  of  the  case,  of  ray  opinion  concerning 
the  irreducibility  of  the  rupture,  and  that  it  had  no  share  in  the 
present  complaint:  at  the  same  time  desiring  my  colleague  to  ex- 
amine for  himself.  We  tried  at  reduction  without  success,  but 
he  thought  that  there  was  still  a  stricture.  The  doctor  ordered 
bleeding,  clysters,  and  cathartics:  the  last  were  immediately  re- 
jected by  vomit,  and  the  clyster  came  away  without  any  mixture 
of  faeces.  Bleeding  was  repeated  ad  deliquium;  the  tobacco- 
smoke  was  injected,  but  all  to  no  purpose.  The  operation  was 
proposed;  but  as  the  case  did  not  appear  to  me  to  require  it,  I 
could  not  second  the  motion:  it  was,  however,  mentioned  to  the 
patient,  who  would  not  consent  unless  I  would  say  that  1  (bought 
it  necessary,  and  believed  it  would  be  successful:  I  could  not  say 
either,  because  I  believed  neither.  Every  thing  else  that  art 
could  suggest  or  practise,  was  tried;  but  on  the  sixth  day  he  died. 

As  it  had  been  supposed  that  I  was  wrong  and  positive,  I  was 
very  glad  that  his  friends  chose  to  iuive  him  opened. 

The  hernial  sac  was  thick  and  hard,  and  contained  a  large  por- 

VOL.   I.  3  H 


436  6BSfeilVAtlONS  ON  RUPTURES. 

tion  of  omentum,  a  piece  of  the  ileum,  and  a  portion  of  the  colou, 
all  perfectly  sound,  free  from  inflammation  or  stricture,  and  irre- 
turnable  only  from  quantity.  But  the  intestine  jejunum  was 
greatly  distended,  highly  inflamed,  and,  in  some  parts,  sphace- 
lated. 


CASE   XVII. 

John  Dewell,  a  man  about  thirty,  was  brought  into  Sf.  Bar- 
tholomew's, labouring,  as  was  supposed,  under  an  incarcerated 
hernia.  He  had  not  had  a  stool  for  three  days, .  although  he  had 
taken  both  purges  and  clysters:  he  vomited  almost  incessantly, 
his  pulse  was  hard  and  frequent,  but  not  full,  and  his  countenance 
bespoke  death. 

He  had  a  rupture;  it  was  on  the  right  side,  was  clearly  intes- 
tinal, was  soft,  easy,  occasioned  no  pain  upon  being  handled,  and 
seemed  to  be  capable  of  reduction;  but  after  many  trials,  I  found 
that  I  could  not  accomplish  that  end,  notwithstanding  I  used  my 
utmost  endeavours;  all  which  gave  the  man  no  uneasiness,  and 
therefore  satisfied  me,  that  his  symptoms  did  not  arise  from  his 
hernia,  which  was  also  the  patient's  own  opinion. 

Mr.  Nourse  coming  into  the  ward,  I  desired  him  to  look  at  the 
man:  he  thought  that,  notwithstanding  the  seemingly  quiet  state 
of  the  rupture,  a  small  portion  of  gut  might  be  so  engaged,  as  to 
cause  his  present  mischief,  and  therefore  that  the  operation  was 
warrantable  and  proper. 

Supposing  it  to  be  right  at  all,  it  could  not  be  done  too  soon, 
and  therefore  we  set  about  it  immediately. 

The  hernial  sac  was  formed  by  the  tunica  vaginalis:  it  contain- 
ed a  portion  of  intestine  ileum,  which  had  contracted  a  slight  co- 
hesion with  the  testicle,  but  was  so  perfectly  free  from  stricture, 
that,  when  we  had  loosened  it  from  its  connexion,  we  returned  it 
into  the  belly  without  dividing  the  tendon. 

I  was  indeed  afraid  that  the  man  would  have  died  before  we 
could  have  got  him  to  bed,  but  he  lived  till  the  next  day. 

A  portion  of  the  colon  within  the  belly  had  been  in  a  state  of 
inflammation,  was  now  plainly  mortified,  and  quite  black. 


OBSERVATIONS  ON  RUPTURES.  427 


CASE  XVIII. 

I  vVas  desired  to  be  present  at  the  opening  of  the  body  of  a 
gentleman,  whose  disease  and  death  had  occasioned  some  alter- 
calion  among  those  who  had  attended  him. 

The  account  given  of  him  while  living  was,  that  to  the  age  of 
fifty-six  he  had  enjoyed  an  uninterrupted  state  of  health. 

That,  at  the  age  of  forty,  he  discovered  a  rupture,  for  which  he 
immediately  took  advice,  and  put  on -a  truss.  That  the  truss  not 
answering  the  purpose,  he  soon  threw  it  aside,  and  suffered  his 
rupture  to  take  its  course.  That  it  gradually  increased  until  it 
became  both  visible  and  troublesome.  That  he  then  applied  to 
Mr.  Sainthill  and  Mr.  Samuel  Sharpe,  both  of  whom  endeavoured 
to  reduce  it,  but  in  vain,  and  both  advised  him  to  wear  a  suspen- 
sory bag,  which  he,  from  that  time,  had  constantly  done.  That 
from  that  time  he  had  never  complained  of  any  uneasiness  but 
what  was  occasioned  by  its  mere  weight.  That  he  verj"  seldom 
missed  having  a  stool  every  morning.  That  about  two  years  be- 
fore his  death,  he  began  to  complain  of  frequent  pain  about  his 
bladder  and  fundament.  That  these  pains  had  affected  him  near 
three  months  before  he  found  any  alteration  in  his  fsecal  dis- 
charge; but  that  from  that  time  he  had  been  constantly  costive; 
and  for  the  last  six  months  had  never  passed  a  stool  without  a 
very  stimulating  purge,  and  even  then  with  great  difficulty.  That 
he  had  frequently  taken  advice,  had  a  variety  of  medicines  pre- 
scribed, from  none  of  which  he  ever  reaped  any  other  than  the 
temporary  benefit  of  purging.  That  in  all  this  time  no  alteration 
bad  ever  been  found  or  perceived  in  his  rupture,  either  regarding 
its  size,  or  any  other  circumstance.  That  for  seven  or  eight 
weeks  before  his  death,  he  had  worn  a  very  morbid  aspect,  was 
become  extremely  emaciated,  and  had  totally  lost  all  appetite;  his 
pains  also  being  more  frequent  and  more  acute.  And  that,  for  the 
last  week,  he  neither  had,  nor  could  obtain,  any  the  smallest  de- 
gree of  stool. 

This  symptom  had  been,  by  those  who  were  called  to  him  last. 


428  OBSERVATIONS  ON  RUPTURES. 

attributed  to  his  hernia;  and  the  operation  had  been  much  pressed 
pn  one  side,  and  objf  cted  to  on  the  other. 

The  Ijernial  sac  was  old,  large,  and  thick;  its  contents  (omen- 
tum) much  hardened;  and  a  considerable  portion  of  the  intestine 
ileum  both  perfectly  sound  and  unaltered,  and  not  bound  by  the 
smallest  degree  of  stricture.  The  stomach,  liver,  spleen,  and 
small  intesiines,  without  blemish,  but  considerably  disiended;  but 
about  five  inches  of  that  part  of  the  colon  nearest  to  the  rectum 
was  so  contracted,  that  it  was  quite  impervious;  and  so  hardened, 
that  it  was  like  nothing  so  little  as  a  portion  of  gut. 


CASE  XIX. 

A  MAN,  about  forty,  was  brought  to  St.  Bartholomew's  with  a 
supposed  incarceraied  hernia. 

He  had  a  very  swollen,  tight  belly,  a  frequent  pain  and  vomit- 
ing, and  no  stools;  and  this  had  been  the  case  for  three  days,  during 
which  time  very  proper  attempts  had  been  made  both  for  reduction 
and  passage. 

Nci.her  the  scrotum,  nor  the  parts  about  the  groin,  seemed  to 
indicate  that  the  seat  of  the  evil  was  there,  ah  bough  the  parts 
were  certainly  too  tense,  and  a  portion  of  iniestine  was  palpably 
in  a  hernial  sac.  It  was  Mr.  Crane's  week,  who  was  out  of 
London;  and  Mr.  Edmund  Pitt,  who  acted  for  him,  desired  me  to 
assist  in  the  operation,  which  was  thought  necessary,  as  no  dis- 
charge per  anum  could  be  procured. 

The  hernial  sac  was  of  the  congenial  kind,  and  contained  a 
portion  of  small  iniestine,  which  did  not  seem  much,  if  at  all, 
bound  by  the  tendon,  but  it  was  so  strongly  and  universally  ad- 
herent to  the  neck  of  the  sac,  thatit  was  impossible  to  think  of 
separating  it.  A  very  unpleasant  circumsumce  this.  All  that 
could  be  done  was,  to  set  it  free  from  ail  possible  slriciure, 
and,  if  siools  could  be  procured,  to  act  afterwards  as  might  be 
necessary. 

Every  means,  of  purge,  clyster,  &c.  was  used,  but  no  pass- 
age procured;  and  on  the  fourth  day  from  that  of  his  admission 
he  died. 


OBSERVATIONS  ON  RUPTURES.  420 

The  piece  of  intestine,  in  the  hernia,  was  that  part  of  the  ileum 

nearest  to  the  colon,  and  which  was  in  good  order,  only  adherent; 
bill  higher  up,  toward  the  j(;jnnum,  it  was  absolutely  impervious 
for  more  than  three  inches  in  lengih. 

I  have  seen  two  other  cases  so  nearly  similar,  that  I  need  not 
repeat  them. 

The  following  case  has  some  circumstances  which  may  possibly 
be  worth  the  reader's  notice. 


CASE  XX. 

Thomas  Marshall,  aged  fifty-four,  was  brought  into  St. 
Bartholomew's  hospital,  on  the  25lh  of  May,  1764,  with  a  large, 
painful,  tumefied  scrotum.  The  account  which  he  gave  of  him- 
self was — 

That  in  his  childhood,  he  had  been  afflicted  with  a  gut-rupture, 
for  which  he  had  worn  a  truss  until  the  rupture  was  supposed  to 
have  been  cured.  That  he  had  always  been  a  regular,  temperate, 
and  hard-working  man.  That,  on  the  23d  of  April,  he  fell,  while 
he  was  at  work,  a  sudden,  violent  attack  of  a  colic-pain,  which, 
in  a  few  hours,  was  followed  by  a  slight  purging.  That,  his  pain 
not  ceasing,  he  took  some  tincture  of  rhubarb,  from  which  he  had 
three  or  four  more  motions.  That,  in  the  evening  of  the  second 
day,  he  found  a  considerable  swelling  in  his  groin  and  scrotum,  on 
the  side  where  his  rupture  had  formerly  been.  That,  on  the  third, 
he  went  to  work  again,  although  he  had  much  pain  in  his  btliy, 
and  a  purging.  That,  on  the  fourth,  he  took  something  of  ihe 
cordial  kind,  given  him  by  a  neighbour,  and  staid  at  home  all  that 
day  and  the  next,  during  which  he  was  pretty  easy,  but  had 
several  loose  stools.  That,  on  the  seventh  day  from  that  of  his 
being  first  taken  ill,  he  went  to  work  again,  but  was  again  attack- 
ed with  severe  pain  and  frequent  vomiting:  immediately  after 
which,  he  found  the  swelling  in  his  scrotum  considerably  increas- 
ed. That,  from  Uiis  time,  he  was  so  much  and  so  constanily 
uneasy,  as  to  be  obliged  to  keep  his  bed,  ii  being  the  only  place 
in  which  he  could  put  himself  in  a  tolerably  eas}  posture.  And 
that  during  ihe  whole  time,  from  the  29lh  of  April  to  the  25th 


430  OBSERVATIONS  ON  RUPTURES, 

of  May,  he  had  very  seldom  had  less  than  two  stools  eVery  day, 
often  more. 

The  man  was  much  emaciated,  had  a  quick  pulse,  a  hot  skin, 
and  considerable  thirst:  the  scrotum  was  now  very  much  on  the 
stretch,  hegan  to  put  on  a  purple  kind  of  colour,  and  had,  at  the 
same  time,  a  watery  load  in  its  cellular  membrane;  but  palpably 
contained  a  large  quantity  of  Huid  in  the  tunica  vaginalis  testis. 
The  whole  tumor  had  a  pyriform  kind  of  figure;  the  spermatic 
process  was  hard  and  large,  and  clearly  contained  something 
which  passed  into  it  from  the  belly;  but  which  sometliing  did  not 
descend  below  the  upper  part  of  the  scrotum,  while  the  lower  part 
of  the  saiiae  was  so  distended,  as  to  be  half  way  down  the  thigh, 
and  was  palpably  filled  by  a  fluid. 

The  state  of  the  parts  was  such,  that  it  became  necessary  to  do 
something,  lest  they  should  mortify.  I  made,  with  all  possible 
caution,  an  incision  through  the  loaded  integuments  into  tlie  cavity 
of  the  tunica  vaginalis,  and  gave  discharge  to  near  a  quart  of  the 
most  offensive  brown  liquor:  upon  the  discharge  of  this,  the  lower 
part  all  subsided,  but  the  upper  remained  the  same.  I  then,  with 
a  crooked  probe-pointed  knife,  divided  the  whole  from  below 
upward,  and  found  that  the  bag  containing  the  fluid  was  a  conge- 
nial hernial  sac,  whose  internal  surface  had  all  the  appearance  of 
being  mortified;  and  that  the  body,  in  its  upper  part,  was  a  portion 
of  intestine.  This  portion  ha(^,  on  its  surface,  several  black  and 
truly  sphacelated  spots;  some  larger,  and  some  smaller;  but  the 
gut  was  still  entire,  and  appeared  moderately  distended  with  wind, 
1  passed  my  finger  through  the  opening  in  the  abdominal  muscle, 
and  could  not  find  that  it  made  the  smallest  degree  of  stricture; 
but  found,  at  the  same  time,  that  the  intestine  was  so  firmly  adhe- 
rent to  the  sac,  that,  in  its  present  state,  it  was  equally  impossible 
to  return,  as  to  detach  it.  That  night  the  man  had  two  good 
stools;  and  next  morning,  when  I  expected  to  have  found  him 
dead,  he  was  considerably  better. 

I  again  examined  the  parts,  to  see  whether  the  intestine  could 
be  returned;  but  again  found  that,  had  it  been  advisable,  it  was 
impracticable.  The  third  day  he  was  still  better,  and  had  a 
figured  stool. 

As  it  appeared  highly  improbable,  that  the  mortified  spots  on 


OBSERVATIONS  ON  RUPTURES.  431 

the  gut  should  cast  off  without  leaving  a  breach  in  the  intestine, 
I  thought  that  the  best  that  could  happen,  would  be  a  discharge 
of  faeces  through  the  wound,  at  least  for  a  time:  but  I  was  mis- 
taken; for  at  the  end  of  five  days,  during  which  he  had  taken  the 
bark  freely,  all  the  eschars  cast  off,  by  a  florid  good  incarnation; 
and,  leaving  no  breach  at  all,  the  man  became  easy,  cheerful,  and 
began  to  take  nourishment. 

From  this  time,  the  portion  of  intestine  in  the  groin  seemed 
daily  to  retire  upward,  and  become  less  visible;  and  I  began  to  en- 
tertain hope  that  we  should  see  a  very  fortunate  termination  of 
this  very  miserable  case.  For  the  space  of  ten  days  he  took  the 
bark  freely,  and  seemed  every  day  better  and  better;  but  at  the 
end  of  that  time,  he  became  again  feverish  and  languid.  Instead 
of  his  usual  freedom  of  stool,  none  could  be  procured,  and  he 
died. 

The  prolapsed  gut  had  retired  so  much,  that,  had  the  man  liv- 
ed, I  make  no  doubt  that  it  would  have  been  included  within  the 
sore,  and  been  firmly  healed  over:  the  places  which  had  been 
sphacelated  were  quite  healed;  but  about  four  inches  of  that  part 
of  the  intestine,  which  was  just  within  the  belly,  was  so  contracted 
as  to  become  quite  impervious,  and  perfectly  scirrhous. 

The  intelligent  will,  I  make  no  doubt,  remark  on  some  parts 
of  this  case;  and  therefore  I  shall  trouble  him  with  one  only, 
which  is,  that  sphacelated  spots  on  the  surface  of  an  intestine  are 
not  always,  and  absolutely,  a  prohibition  against  returning  such 
intestine  into  the  belly. 


CASE  XXL 

I  WAS  desired  to  meet  Dr.  De  Valangin,  Mr.  Godman,  and  Mr. 
Bbigue,  in  the  case  of  a  hernia  with  stricture. 

The  patient  was  a  man  about  the  middle  of  life;  his  rupture 
was,  I  think,  on  his  left  side;  and  when  I  saw  him  he  had  not 
had  a  stool  for  several  days,  though  the  usual  means  had  been 
used.  Upon  examining  the  parts,  they  made  as  bad  an  appearance 
as  possible:  they  had  been  tumid,  full,  and  inflamed;  they  were 
now  sunk,  flaccid,^  and  completely   mortified:   notwithstanding 


432  OBSERVATIONS  ON  RUPTURES. 

which,  I  could  not  say  that  the  man  appeared  so  near  to  death  as 
such  an  appearance  would  indicate;  but  at  the  same  time  so  ma- 
terially ill  that  I  could  not  suppose  that  he  could  receive  any 
ben'-fit  from  the  art  of  surgery. 

The  true  intent  of  the  operation,  that  of  setting  the  gut  free  from 
the  stricture,  was  of  no  consideration  here:  the  stricture  had  done 
all  its  mischief:  if  the  man  was  to  live,  (he  mortified  parts  must 
cast  off;  and  if  he  was  to  die,  I  thought  it  was  better  that  we 
should  not  even  appear  to  have  a  share  in  his  death,  by  an  opera- 
tion which  I  thought  could  not  be  serviceable,  and  might  be  mis- 
construed. 

This  was  truly  my  opinion,  and  I  gave  it  as  such.  But,  over- 
come bv  the  importunity  of  the  patient's  wife,  and  to  avoid  seeming 
to  be  either  careless  or  brutal,  I  was  prevailed  on  to  divide  the 
parts.  The  scrotum,  integuments  in  the  groin,  and  hernial  sac, 
were  completely  and  truly  mortified;  the  por'ion  of  intestine,  which 
certainly  was  not  less  than  three  inches,  was  in  the  same  state, 
sunk,  empty,  (having  burst,)  and  as  black  as  a  coal;  the  offence 
was  terrible,  but  the  man  suffered  no  pain,  as  the  parts  were  totally 
void  of  sensation. 

I  contented  myself  with  merely  dividing  the  scrotum  and  hernial 
sac,  and  left  the  rotten  intestine  as  it  was,  lying  in  the  groin  on 
the  outside  of  the  ring,  concluding  that  a  verv  short  space  of  time 
would  determine  the  poor  man's  fate,  and  that  not  favourably. 
The  gentlemen  whom  I  had  met  continued  to  attend,  and  to  take 
care  of  him;  the  mortified  parts  cast  off,  he  discharged  his  faeces 
through  his  wound  for  some  time,  but  that,  in  no  great  lengih  of 
time,  ceased;  and  within  the  space  of  a  month,  I  saw  him  in  very 
good  health,  discharging  all  his  fagces  per  anum,  and  having  only 
a  small,  clean,  and  healing  sore,  where  his  wound  had  been. 
How  the  faeces  passed  from  the  ileum  to  the  colon,  after  the  mor- 
tified parts  were  thrown  off,  I  am,  considering  the  size  of  the 
portion  of  gut,  really  at  a  loss  to  account  for;  but  very  sure  I 
am,  that,  if  the  advice  given  by  all  writers,  in  these  cases,  to  cut 
off  the  piece  of  mortified  intestine,  and  fasten  the  sound  part  to  the 
upper  part  of  the  wound,  had  been  followed,  the  man  would  have 
passed  the  remainder  of  his  life  in  a  much  more  unpleasant  man» 
ner. 


OBSERVATIONS  ON  RUPTURES.  433 


HERNIA  VESICJE    URINARIA. 

A  HERNIA  formed  by  a  protrusion  of  a  portion  of  the  urinary 
bladder  through  the  opening  in  the  abdominal  muscle  into  the 
groin  or  scrotum,  is  a  disease  sometimes,  but  not  very  frequently, 
met  with. 

It  has  been  taken  notice  of  by  many  writers  of  character,  and 
has  been  accurately  described  by  Mons.  Verdier,  and  Mr.  Samuel 
Sharpe. 

Whoever  is  acquainted  with  the  structure  and  disposition  of  the 
peritoneum,  without  which  knowledge  he  cannot  understand  a 
hernia  at  all,  knows  that  the  bladder  is  only  covered  in  part  by 
that  membrane,  and  that  its  inferior  and  lateral  parts  lie  on  the 
outside  of  it,  in  the  tela  cellulosa. 

That  portion  of  the  bladder  which  is  liable  to  this  protrusion, 
is  not  covered  by  the  peritoneum;  consequently,  when  it  is  thrust 
forth,  it  does  not  carry  with  it  any  part  of  the  said  membrane; 
and  therefore  cannot  have  what  is  called  a  hernial  sac;  in  which  it 
differs  from  every  other  kind  of  hernia. 

The  two  following  are  the  only  cases  I  ever  met  with. 


CASE  XXII. 

A  POOR  fellow,  who  worked  with  a  farmer  at  Islington,  came 
to  St.  Bartholomew's  with  a  large,  troublesome  swelling  in  his 
scrotum.  The  tumor  was  large,  tense,  of  a  pyriform  figure,  pal- 
pably contained  a  fluid,  gave  no  pain  but  from  its  weight  when 
full,  and  had  every  mark  of  a  hydrocele,  except  that  the  testicle 
was  perfectly  distinguishable  at  its  bottom. 

While  I  was  hesitating  concerning  this  circumstance,  the  man 
said,  '  Sir,  I  can  get  rid  of  it  all  by  pissing,  but  it  fills  again  in  a 
a  few  hours,  especially  if  I  drink. ' 

Upon  my  seeming  to  disbelieve  what  he  said,  he  took  up  his 
scrotum,  and  squeezing  it  together  with  some  violence,  discharged 
the  whole  by  the  urethra. 

VOL.  I.  3  I 


434  OBSEKVATlOiXS  ON  IIUPTL'RES. 


CASE  XXIIJ. 


A  i!Ov,  iiboiit  six  years  okl,  was  seized  with  au  acute  pain  about 
the  region  of  ihe  pubes:  it  lasted  near  an  hour  and  a  half,  and 
suddenly  ceasing,  he  became  perfectly  easy.  During  the  time 
his  pain  lasted  he  could  not  discharge  a  drop  of  water,  though  he 
endeavoured  so  to  do;  but  as  it  ceased  he  pissed  freely.  In  a  few 
days  after,  a  small  tumor  was  discovered  about  the  size  of  a  pea, 
in  the  spermatic  process,  just  below  the  groin:  it  gave  the  child 
no  pain,  and  therefore  no  notice  was  taken  of  it.  By  slow  de- 
grees it  descended  lower  and  lower,  and  as  it  descended,  it  seem- 
ed to  increase  in  size.  When  it  had  got  to  the  upper  part  of  the 
scrotum,  it  was  observed  to  be  considerably  enlarged;  and  the 
Iwy  now  found  himself  more  frequently  urged  to  make  water,  but 
without  pain  or  diffiulty.  He  was  examined  by  a  practitioner  or 
two  in  his  neighbourhood,  who,  not  knowing  what  to  make  of  it, 
advised  the  letting  it  alone.  Withhi  the  space  of  five  years  it 
got  down  to  the  bottom  of  the  scrotum,  and  when  it  was  there  it 
was  observed  to  increase  much  faster  than  it  had  done  before. 
The  boy  Vv^as  at  a  considerable  distance  from  London,  and  it  ill 
suited  his  friends  to  send  him  thither,  so  that  another  year  passed 
before  lie  was  sent  up;  which  was  done  at  the  age  of  thirteen,  the 
swelling  being  now  troublesome  upon  any  motion. 

Some,  who  first  saw  him,  deemed  it  a  scirrhous  testicle,  and 
advised  castration,  to  which  the  friends  of  the  boy  would  not 
submit. 

From  the  most  careful  examination  I  could  make,  I  could  not 
think  it  was  formed  by  the  testicle;  but  on  the  other  hand  I  could 
not  find  any  testicle  on  that  side. 

The  swelling  was  perfectly  equal  in  its  surface,  was  indolent, 
had  a  stony,  incompressible  kind  of  hardness,  was  troublesome 
from  its  weight,  but  never  occasioned  pain  in  the  back  or  loins: 
it  had  all  the  appearance  of  being  dependant  from  the  spermatic 
process;  which  process,  though  it  had  neither  the  feel,  nor  the  ap- 
pearance of  being  diseased,  yet  was  larger  than  it  should  be,  and 
than  that  on  the  other  side.     The  perfect  equality  of  the  tumor. 


OBSERVATIONS  ON  RUPTURES.  435 

its  being  perfectly  free  from  pain,  even  ivhen  pressed  harcl,  and 
its  extreme  incompressibilily,  led  rne  to  believe  it  war,  not  the  tes- 
ticle; but  this  was  merely  negative  informalion.  The  trouble  it. 
now-  gave  the  boy,  and  ils  disposition  to  increase,  seemed  to  au- 
thorise its  removal;  and  the  state  botli  of  the  part  and  of  the  child 
were  no  prohibitions.  1  therefore  proposed  and  undertook  it.  j 
made  an  incision  through  the  skin  and  cellular  membrane,  the 
whole  length  of  the  process  and  scrotum,  by  means  of  which  I 
discovered  a  firm,  white,  membranous  bag,  or  cyst,-  connected 
loosely  with  the  cellular  membrane,  in  the  same  manner  as  a  her- 
nial sac.  I  dissected  all  the  anterior  part  of  this  bag  quite  clean. 
.  and  found  that,  as  I  traced  it  upward,  it  became  narrower,  and 
seemed  to  proceed  from  the  upper  part  of  the  groin.  This  deter- 
mined me  to  try  if  I  could  not  clear  it  from  its  posterior  con- 
nexion; in  doing  which,  I  discovered  a  testicle  which  lay  immedi- 
ately behind  the  body  forming  the  tumor,  and  was  small,  (lat,  and 
compressed. 

The  dissection  of  this,  and  of  the  spermatic  chord  from  the 
bag  and  from  its  neck,  which  I  was  obliged  to  do  in  order  to  pre- . 
serve  the  testicle,  took  up  some  time,  and  gave  me  some  trouble; 
but  when  I  had  finished  it,  I  found  that  the  cyst  was  dependant 
from,  and  continuous  with,  a  membranous  duct  about  the  breadth 
of  the  largest  wheat-straw,  or  what  it  was  more  like  to,  a  human 
ureter?  which  passed  out  from  the  abdomen  through  the  opening 
in  the  muscle. 

When  I  had  pe*fectly  cleared  this  duct  from  all  connexion  with 
the  spermatic  chord,  I  cut  it  off  immediately  above  the  tumor; 
and  upon  the  division  there  issued  forth  about  four  ounces  of 
a  clear  liquor;  and  the  mouth  of  the  cyst,  expanding  itself, 
disclosed  a  stone,  exactly  resembling  what  is  found  in  the  human 
bladder. 

As  there  was  not  the  least  appearance  of  fluid,  either  in  the  bag 
or  in  its  neck,  before  the  division,  its  immediate  effusion,  and  the 
appearance  of  the  stone,  induced  me  to  believe,  that  the  case  was 
a  hernia  cystica.  In  order  to  be  certain,  I  staid  some  time;  and 
when  I  thought  that  some  quantity  of  urine  might  have  passed 
from  the  kidneys.  T  desired  the  boy  to  try  to  make  water:  he  did 


436  .   OBSERVATIONS  ON  RUPTURES, 

SO,  and  a  large  stream  of  urine  flowing  through  the  wound,  in- 
stead of  the  urethra,  put  the  matter  out  of  all  doubt. 

He  was  dressed  superficially,  had  no  one  bad  symptom,  though 
a  portion  of  the  bladder  was  totally  removed:  his  urine  came 
through  the  wound  in  his  groin  for  about  a  fortnight;  but  as 
that  wound  healed,  it  resumed  its  natural  course,  and  the  pa- 
tient has  remained  free  from  complaint  ever  since,  except  that 
the  natural  size  of  his  bladder  being  lessened  by  the  extirpa- 
tion of  a  part,  he  is  obliged  to  discharge  his  uiine  rather  more 
frequently. 


CASE  XXIV. 

AN  OVARIAN  HERNIA. 

A  HEALTHY  youug  womau  about  twenty-three  was  taken  into 
St  Bartholomew's  hospital  on  account  of  two  small  swellings,  one 
in  each  groin,  which  for  some  months  had  been  so  painful,  thai 
she  could  not  do  her  work  as  a  servant. 

The  tumors  were  perfectly  free  from  inflammation,  were  soft, 
unequal  in  their  surface,  very  moveable,  and  lay  just  on  the  out- 
side of  the  tendinous  opening  in  each  of  the  oblique  muscles, 
through  which  they  seemed  to  have  passed. 

The  woman  was  in  full  health,  large  breasted,  stout,  and  men- 
struated regularly;  had  no  obstruction  to  the  discharge  per  anum; 
nor  any  complaint  but  what  arose  from  the  uneasiness  these  tumors 
gave  her,  when  she  stooped  or  moved  so  as  to  press  them. 

She  was  the  patient  of  Mr.  Nourse.  He  let  her  blood  and 
purged  her,  and  took  all  possible  pains  to  return  the  parts  through, 
the  openings  through  which  they  had  clearly  passed  out. 

He  found  all  his  attempts  fruitless,  as  did  Mr.  Sainlhill  and 
myself;  and  the  woman  being  incapacitated  from  getting  her  bread, 
and  desirous  to  submit  to  any  thing  for  relief,  it  was  agreed  to 
remove  them. 

The  skin  and  membrana  adiposa  being  divided,  a  fine  mem- 
branous bag  came  into  view,  in  which  was  a  body  so  exactly  re- 
sembling a  human  ovarium,  that  it  wa"?  impossible  to  take  it  for 


OBSERVATIONS  OW  IW L'TU RLH .  437 

iinj  thing  else;  a  ligature  was  made  on  it,  close  io  the  tfcndon, 
and  it  was  cut  off.  The  same  operation  was  done  on  the  other 
side;  and  the  appearance,  both  at  the  iime  of  operating,  and  in 
the  examination  of  the  parts  removed,  was  exactly  the  same. 

She  has  enjoyed  good  health  ever  since,  but  Is  become  thinner 
and  more  apparently  muscular;  her  breasts,  which  were  large, 
are  gone;  nor  has  she  ever  menstruated  since  the  operation,  which 
is  now  some  years. 


EJNfe  OF  VOL.   1. 


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